How to optimize Cerebrospinal Fluid (CSF) procedure?

From the Guidelines

To optimize the CSP (Cerebrospinal fluid puncture) procedure, use an atraumatic narrow-bore (≥22-gauge) needle, place the patient in the lateral recumbent position, and collect <30 mL of CSF, as these methods have been shown to reduce the risk of adverse events, including headache, back pain, and discomfort, as supported by the most recent study 1.

Key Recommendations

• Evaluate potential contraindications and identify patient-related risk factors before the procedure 1
• Use atraumatic needles, which have been consistently shown to have a favorable safety profile compared to cutting-bevel needles, with a relative risk of post-LP headache of 0.40 [95% CI, 0.34–0.47], P < .0001 1
• Avoid multiple attempts (≤4) and use passive rather than active withdrawal of CSF when feasible 1
• Communicate effectively with the patient to allay fears and concerns, and provide detailed instructions on the procedure and what to expect 1

Considerations for Needle Selection

• The choice of needle depends on the patient’s age, weight, and the purpose of the procedure, with smaller needles (≥24 gauge) recommended for most patients, but larger needles may be needed for obese patients or those with severe spine deformity 1
• Standard-length needles (70–90 mm) are used in adults, but longer needles may be needed in obese patients, although these can be more difficult to use and increase the risk of complications 1

Importance of Patient Positioning and CSF Collection

• Placing the patient in the lateral recumbent position can help reduce the risk of adverse events, including headache and back pain 1
• Collecting <30 mL of CSF can also help reduce the risk of complications, including blood contamination and CSF leakage 1

From the Research

Optimising CSP Procedure

To optimise the CSP (Chlorhexidine Skin Preparation) procedure, it is essential to consider the timing of preoperative antibiotic prophylaxis. The following points highlight the key findings:

• The ideal time to administer preoperative antibiotics for cefazolin is 40 minutes prior to incision, and for clindamycin is 45 minutes prior to incision 2.
• The Centers for Disease Control and Prevention (CDC) guidelines recommend administering the chosen antibiotic within 60 minutes prior to incision 2.
• A study found that higher SSI rates were observed for timing more than 60 minutes prior to incision, but not after incision 3.
• Another study found no significant association between prophylactic antibiotic timing and SSI, but noted that the SSI risk varies by patient and procedure factors as well as antibiotic properties 3.
• The use of enoxaparin as VTE prophylaxis in ICU patients was associated with a similar prevalence of DVT and PE compared with unfractionated heparin, but a higher mortality rate was seen in the UFH group 4.
• Enoxaparin has been shown to be a safe and effective agent in the treatment of a whole spectrum of acute coronary syndromes, with similar efficacy and safety in the prevention and treatment of venous thromboembolism 5.
• A study found no conclusive evidence of a difference in SSI risk after SAP administration 60-30 minutes or 30-0 minutes before incision 6.

Key Considerations

When optimising the CSP procedure, consider the following:

• The timing of preoperative antibiotic prophylaxis is crucial in reducing the risk of surgical site infections.
• The choice of antibiotic and its pharmacokinetic profile should be taken into account when determining the ideal time for administration.
• Patient and procedure factors, as well as antibiotic properties, can influence the risk of SSI.
• The use of enoxaparin as VTE prophylaxis may be associated with a higher mortality rate compared to unfractionated heparin.
• Enoxaparin has been shown to be a safe and effective agent in the prevention and treatment of venous thromboembolism.