What is the protocol for a guarded Lumbar Puncture (LP) procedure in pediatric patients?

From the Guidelines

A guarded lumbar puncture procedure in young children requires careful preparation and technique to ensure safety and success, and I strongly recommend using atraumatic (pencil-point) needles to minimize the risk of post-dural-puncture headache, as supported by the most recent and highest quality study 1. When performing a lumbar puncture in young children, it is essential to consider the potential risks and benefits, particularly in terms of morbidity, mortality, and quality of life.

• The use of atraumatic needles has been shown to reduce the incidence of post-dural-puncture headache, which can be a significant complication of lumbar puncture 1.
• In addition to the type of needle used, other factors such as patient positioning, local anesthesia, and procedural sedation can also impact the safety and success of the procedure.
• For local anesthesia, applying EMLA cream (lidocaine 2.5% and prilocaine 2.5%) to the puncture site 60 minutes before the procedure, followed by 1% lidocaine infiltration (maximum 4-5 mg/kg), can be effective in managing pain.
• Procedural sedation with midazolam (0.05-0.1 mg/kg IV or 0.5 mg/kg intranasal) for anxiolysis, combined with ketamine (1-2 mg/kg IV) for analgesia in highly anxious children, may also be considered.
• Positioning the child in lateral recumbent position with knees flexed toward the chest, ensuring proper alignment of the spine, and using the smallest appropriate spinal needle (typically 22G) and inserting at the L3-L4 or L4-L5 interspace, below the termination of the spinal cord, can help minimize the risk of complications.
• Non-pharmacological techniques, including distraction, comfort positioning, and having a parent present, can significantly reduce anxiety and improve the overall experience for the child.
• Monitoring vital signs throughout the procedure and post-procedure care, including keeping the child recumbent for 1-2 hours to minimize headache risk, are also crucial aspects of a guarded lumbar puncture procedure. The evidence from the study 1 suggests that the use of atraumatic needles can significantly reduce the risk of post-dural-puncture headache, and this should be considered a key component of a guarded lumbar puncture procedure in young children.

From the Research

Guarded Lumbar Puncture Procedure in Young Children

• The guarded lumbar puncture procedure is a useful diagnostic tool in pediatric clinical situations, including ruling out serious intracranial infections in febrile children 2.
• Success rates of lumbar puncture can be optimized by proper positioning, appropriate technique, and enhanced operator skill 2.
• In pediatric oncology, lumbar punctures can be performed with conscious sedation or general anesthesia, with most children, parents, and nurses preferring conscious sedation 3.
• However, younger children may not cooperate with conscious sedation, and alternative approaches, such as having a pediatric anesthesiologist available, may be necessary 3.

Pain Management during Lumbar Puncture

• Lumbar puncture can cause considerable pain and discomfort in newborn infants, and adequate analgesia is crucial to manage procedural pain 4.
• Topical anesthetics, such as lidocaine or EMLA, may reduce pain assessed with validated scales, but the evidence is of low certainty 4.
• Systemic treatment, such as opioids or sedatives, may also be used to manage pain during lumbar puncture, but more research is needed to determine their effectiveness 4.

Use of Ultrasound Guidance

• Ultrasound guidance can be used to reduce the number of needle insertion attempts and increase procedure success rates, especially in patients with difficult-to-palpate landmarks 5.
• Ultrasound can be used to more accurately identify the lumbar spine level and mark a needle insertion site, and can be used in both lateral decubitus and sitting positions 5.
• Novice providers should undergo simulation-based training before attempting ultrasound-guided lumbar puncture on actual patients 5.

Sedation Practices

• Sedation is often used to reduce pain and anxiety in pediatric patients with acute lymphoblastic leukemia undergoing lumbar punctures 6.
• Intravenous and inhaled anesthetics, such as propofol and midazolam, are commonly used for sedation, while local anesthetics alone are used less frequently 6.
• The majority of children's hospitals in the United States use intravenous and inhaled anesthetics for routine therapeutic lumbar punctures in pediatric patients with acute lymphoblastic leukemia 6.