Iowa Neonatology Handbook: Procedures

Lumbar Puncture

Iowa Neonatology Fellows
Peer Review Status: Internally Peer Reviewed

I. Lumbar puncture (LP) should be performed for the following indications:

A. Diagnosing or ruling out sepsis in the neonatal period. Meningitis may be present in as many as 25% of cases of neonatal sepsis. The choice and dose of antibiotics and the duration of antibiotic therapy may be longer for patients with meningitis than with sepsis.

B. To monitor efficacy of antibiotic therapy with repeat cell count and culture, or occasionally drug levels of antibiotics.

C. LP is sometimes used as a treatment for communicating hydrocephalus.

II. Possible Contraindications:

A. Severe bleeding diathesis

B. Superficial infection at the LP site

C. Vertebral anomalies

D. Increased ICP with decreased communication of spinal fluid

E. Severe cardiorespiratory instability of patient

III. Technique:

A. Have assistant restrain patient in either lateral decubitus or sitting position with spine flexed. The head need not be flexed too far, as some infants develop increased respiratory difficulty with flexing of the head. Some people prefer the lateral decubitus for the more unstable patients. Complete immobilization of the spine is extremely important in larger and stronger infants.

B. Palpate the spinous process that is even with the iliac crests. This is L4. Locate one interspace above (L3-L4) or one space below (L4-L5) as the site.

C. Glove.

D. Prep 3 times with alcohol and sponges from the LP tray. Drape with the drape in the tray or with a Steridrape R.

E. Use 22-gauge short spinal needle from kit or one with a clear hub from the cupboard. Hold needle/stylet with both hands, thumb on the hub and first fingers guiding into the interspace, aiming for the umbilicus. Insert slowly. One may not feel "pop" as is common with the larger children. Remove stylet and check for CSF. Return stylet and advance if no return. One may need to rotate the needle slightly to increase or initiate the flow. If unsuccessful repeat attempt in next interspace up or down, but never go above the L2-L3 interspace.

F. When collecting for diagnostic purposes, the spinal fluid should be collected in the tubes from the kit in the following order; Tube 1 - culture and STAT gram stain, Tube 2 - glucose and protein, Tube 3 - cell count.

G. The stylet should be replaced and the needle removed, covering the site with a 2 x 2 gauze until a bandage can be placed.

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