How do I perform a spinal tap on a neonate?

From the Guidelines

A spinal tap (lumbar puncture) on a neonate should only be performed by trained medical professionals, with careful consideration of the potential risks and benefits, and after weighing the need for the procedure against the potential for pain and complications, as emphasized by the American Academy of Pediatrics 1. The procedure involves positioning the infant in a lateral decubitus position with knees flexed toward the chest, or in a sitting position with support. After sterile preparation with chlorhexidine or povidone-iodine and local anesthesia (1% lidocaine, 0.1-0.2 mL), a 22-gauge spinal needle is inserted at the L3-L4 or L4-L5 interspace, below where the spinal cord ends. Some key points to consider when performing a spinal tap on a neonate include:

• Advance the needle slowly until cerebrospinal fluid (CSF) flows, typically 1-2 cm deep.
• Collect 1-3 mL of CSF in three or four sterile tubes for analysis.
• Monitor vital signs throughout and apply a sterile dressing afterward. Potential complications include bleeding, infection, post-procedure headache, and herniation (rare but serious). Contraindications include increased intracranial pressure, infection at the puncture site, bleeding disorders, or cardiorespiratory instability. The procedure is essential for diagnosing meningitis, encephalitis, or subarachnoid hemorrhage in neonates who present with fever, irritability, lethargy, or seizures, and the decision to perform a lumbar puncture should be guided by clinical judgment and consideration of the individual patient's risk factors, as noted in the clinical policy for well-appearing infants and children younger than 2 years of age presenting to the emergency department with fever 1. Additionally, the use of topical anesthetic agents, such as tetracaine gel or Eutectic Mixture of Local Anesthetics (EMLA), may provide pain relief during the procedure, as suggested by the prevention and management of procedural pain in the neonate: an update 1. It is also important to consider the prevention and management of pain in the neonate, as repeated painful exposures have the potential for deleterious consequences, and proven and safe therapies are currently underused for routine minor yet painful procedures, as highlighted by the prevention and management of pain in the neonate: an update 1.

From the Research

Performing a Spinal Tap on a Neonate

To perform a spinal tap on a neonate, it is essential to consider the clinical indications and potential risks associated with the procedure 2. The following steps and considerations can be taken into account:

• Indications for a neonatal lumbar puncture: A lumbar puncture can be performed in neonates with suspected sepsis, meningitis, or other conditions that require cerebrospinal fluid analysis 3.
• Preparation and positioning: The neonate should be properly positioned, either in the lateral decubitus or sitting position, to facilitate the procedure 4. However, the lateral decubitus position may increase the risk of bradycardia and oxygen desaturation 4.
• Procedure: The procedure should be performed by a trained healthcare professional, taking into account the neonate's anatomy and potential complications 5.
• Considerations for neonates under and over 72 hours of age: There is no significant difference in the incidence of meningitis between neonates under and over 72 hours of age, and a lumbar puncture is recommended in all neonates with suspected sepsis regardless of age 3.
• Potential complications: The procedure carries potential risks, including infection, bleeding, and neurological damage 6. Repeated lumbar punctures may increase the risk of CSF infection 6.

Key Considerations

• The decision to perform a spinal tap on a neonate should be made carefully, taking into account the potential benefits and risks 2.
• The procedure should be performed by a trained healthcare professional, with proper positioning and preparation 5, 4.
• The neonate's age, risk factors, and clinical manifestations should be considered when deciding whether to perform a lumbar puncture 3.
• The potential complications and risks associated with the procedure should be carefully evaluated and monitored 6, 4.