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I. INDICATIONS

  1. Obtain cerebrospinal fluid for the diagnosis of central nervous system disorders such as meningitis/encephalitis.

    1. Infections that can be diagnosed are bacterial, viral, fungal, and TORCH (toxoplasmosis, other [usually syphilis], rubella, cytomegalovirus, and herpes simplex virus). Meningitis can be present in as many as 23% of cases of neonatal sepsis, and blood cultures can be negative in up to 38% of infants with meningitis.

    2. Initial sepsis workup (controversial). If central nervous system (CNS) involvement is suspected or blood cultures are positive, some sources recommend a lumbar puncture (LP). Because signs and symptoms of neonatal meningitis are vague and nonspecific, some clinicians advise that all infants with proven or suspected sepsis undergo LP. The American Academy of Pediatrics (AAP) recommends that an LP be performed in any infant with a positive blood culture, when clinical course or laboratory findings highly suggest sepsis, or in an infant with worsening clinical status on antibiotic therapy. Delay the LP in any infant who is critically ill who will not be able to tolerate the procedure. (Confirm that the antibiotic dosage will cover for meningitis.)

  2. Diagnose an inborn error of metabolism. Multiple cerebrospinal fluid (CSF) studies exist that can help delineate different inborn errors of metabolism, including but not limited to amino acid analysis for nonketotic hyperglycinemia and CSF lactate-to-pyruvate ratio for mitochondrial disorders.

  3. Drainage of cerebrospinal fluid in communicating hydrocephalus associated with intraventricular hemorrhage. (Serial LPs for this are controversial.) A Cochrane review (2017) found the following: “There was no evidence that repeated removal of CSF via LP, ventricular puncture or from a ventricular reservoir produces any benefit over conservative management in neonates with or at risk for developing post hemorrhagic hydrocephalus in terms of reduction of disability, death or need for placement of a permanent shunt.”

  4. Aid in the diagnosis of intracranial hemorrhage. CSF studies are indicative but not diagnostic for intracranial hemorrhage. Signs include a large number of red blood cells (RBCs), xanthochromia, increased protein content, and hypoglycorrhachia (abnormally low CSF glucose).

  5. Administration of intrathecal medications. Chemotherapy, antibiotics, anesthetic agents, or contrast material.

  6. Evaluation of antibiotic efficacy in CNS infections by examining CSF fluid.

  7. Diagnose CNS involvement with leukemia.

II. EQUIPMENT

LP kit (usually contains 3–4 sterile specimen tubes; 4 are often necessary); sterile drapes; sterile gauze; 20-, 22-, or 24-guage, 1.5-inch spinal needle with stylet (do not use a butterfly needle as it may introduce skin into the subarachnoid space and form a dermoid cyst); 1% buffered lidocaine and/or topical anesthetic (EMLA [eutectic mixture of lidocaine and prilocaine]); 25- to 27-gauge needle, 1-mL syringe; sterile gloves; mask; gown; hat; and skin disinfectant (10% povidone-iodine solution or other unit-approved type), point-of-care ultrasound.

III. PROCEDURE

  1. Contraindications to lumbar puncture include increased intracranial pressure (ICP) (risk of CNS herniation), uncorrected bleeding abnormality (thrombocytopenia or bleeding diathesis), overlying skin infection near puncture site, ...

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