1.LUMBAR PUNCTURE

2. INDICATIONS : Diagnostic : Therapeutic : Infectious Analgesia Meningitis Anesthesia Encephalitis Antibiotics Inflammatory Antineoplastics Multiple Sclerosis Gullain-Barre syndrome Oncologic Metabolic Spontaneous subarachnoidhemorrhage 3. CONTRAINDICATIONS : Increased intracranial pressure Cerebral herniation Impending herniation Possible increased ICP and focal neuro signs Coagulopathy Prior lumbar surgery Severe vertebral osteoarthritis or degenerative discdisease Significant cardiorespiratory compromise Infection near the puncture site Space occupying lesion 4. EQUIPMENT : Spinal needle Less than 1 yr: 1.5in 1yr to middle childhood: 2.5in Older children and adults: 3.5in Three-way stopcock Manometer 4 specimen tubes Local anesthesia Drapes Betadine 5. PROCEDURE : Performed with the patientin the lateral recumbentposition. A line connecting theposterior superior iliaccrest will intersect themidline at approx. the L4spinous process. Spinal needles entering thesubarachnoid space at thispoint are well below thetermination of the spinalcord. 6. LP in older children may beperformed from L2 to L3interspace to the L5 to S1interspace. At birth, the cord ends at thelevel of L3. LP in infant may be performedat the L4 to L5 or L5 to S1interspace. 7. Position the patient: Generally performed in thelateral decubitus position. A pillow is placed under thehead to keep it in the sameplane as the spine. Shoulders and hips arepositioned. perpendicular withthe table. Lower back should be archedtoward practitioner. 8. a. Ligament flavum is a strong, elastic, yellow membrane covering the interlaminar space between the vertebrae.b. Interspinal ligaments join the inferior and superior borders of adjacent spinous processes.c. Supraspinal ligament connects the spinous processes 9. A topical anesthetic (e.g. EMLA cream) can be applied 30 to 60minutes before performing the puncture to minimize pain onpenetration. Either a sitting or lateral decubitus position can be used . Monitor the patient visually and with pulse oximetry for any signsof respiratory difficulty as a result of assumed position. The subarachnoid space must be entered below the level of spinalcord termination. The spine should be flexed maximally to increase spacing betweenspinous processes.Extensive neck flexion, however, should be avoided to minimize achance of respiratory compromise.Make sure the hips and shoulders are aligned & are perpendicularto the bed surface. 10. The patients back should be carefully prepared and drapedusing provided disinfecting solution and drapes. Orient yourself anatomically and find the L4 spinous processat the level of iliac crests Palpate a suitable interspace distal to this level. Infiltrate 2% Lidocaine subcutaneously (without epinephrineto prevent cord infarction should it be introduced into thecord by accident) with a fine needle. A field block can be applied injecting into and on either sideof the interspinous ligaments. Identify the two spinal processes in between which theneedle will be introduced, penetrate the skin and slowlyadvance the tip of the needle at about 10 degrees cephalad(i.e. toward the patients umbilicus). 11. Remove the stylet and check for clear fluid will flow fromthe needle when the subarachnoid space has been penetrated. The ligaments offer resistance to the needle, and a pop isoften felt as they are penetrated. Withdraw the needle leaving the tip in, recheck thelandmarks and slowly progress the needle again. Measure the opening pressure using the manometer byattaching it via a stopcock to the spinal needle. Normal opening pressure ranges from 10 to 100 mm H2O inyoung children and 60 to 200 mm H2O after eight years ofage 12. CSF volume of 1cc obtained in 3 tubes. In the neonate, 2ml in total can be safely removed. In an older child 3 to 6 ml can be sampled dependingon the childs size. Tube 1 is used for determining protein and glucose Tube 2 is used for microbiologic and cytologic studies Tube 3 is for cell counts and serologic tests for syphilis 13. COMPLICATIONS : Herniation Cardiorespiratory compromise Pain Headache (36.5%) Bleeding Infection Subarachnoid epidermal cyst CSF leakage 14. BONE MARROW ASPIRATION 15. INDICATIONS : Diagnostic :- Idiopathic Thrombocytopenic Purpura- Aplastic Anemia- Leukemia- Megaloblastic Anemia- Infections e.g. Kala Azar- Storage disorders e.g. Gauchers disease- PUO- Myelofibrosis Therapeutic :- Bone Marrow Transplantation 16. CONTRAINDICATIONS : Hemorrhagic disorders such as congenitalcoagulation factor deficiencies (eg, hemophilia),disseminated intravascular coagulation andconcomitant use of anticoagulants. Skin infection or recent radiation therapy at thesampling site. Bone disorders such as osteomyelitis orosteogenesis imperfecta. 17. PROCEDURE : Obtain consent from a parent or guardian. If the posterior iliac crest is the chosen site, patients aregenerally placed in the lateral decubitus position or theprone position Sterilize the site with the sterile solution Place a sterile drape over the site, and administer localanesthesia, letting it infiltrate the skin, soft tissues, andperiosteum. After local anesthesia has taken effect, make an incisionthrough which the bone marrow aspiration needle can beintroduced . 18. If a guard is present, should be removed before startingbone marrow aspiration, to ensure adequate depth ofpenetration.. In general, the needle should be advanced at an anglecompletely perpendicular to the bony prominence of theiliac crest. Once the needle passes through the cortex and enters themarrow cavity, it should stay in place without being held. Once the periosteum has been penetrated, pressure is usedto advance the needle through the cortex and rotate theneedle in a semicircular motion, alternating clockwise andcounterclockwise movements. 19. If the patient is in the lateral position, the hip may bestabilized with the other hand to get a better feel for theposition and depth of the needle. The thumb of this hand can be to mark the desired siteand to prevent accidental repositioning of the needle. A slight give will be felt, after which you will feel thatthe needle is fixed solidly within the bone. Remove the stylet and aspirate approximately 1 ml ofunadulterated bone marrow into a syringe. Specimen is taken and is assessed for the presence ofbony spicules. 20. If the specimen shows spicules, the specimen should beused to make smear slides immediately. If spicules are sparse or are not present, a new sampleshould be obtained from a slightly different site. The needle is left in place and sequential syringes arefilled that have been prepared with heparin or otheranticoagulants or preservatives, depending on therequirements for specific studies to withdraw samplesfor additional analysis. Then remove the needle, either after reinserting thestylet or with the syringe attached. 21. COMPLICATIONS : Hemorrhage Infection Persistent pain at the marrow site Retroperitoneal hematomas Trauma to neighboring structures (e.g., lacerationsof a branch of the gluteal artery) and soft tissues