Date of submission November 2014

Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc.) Author: Contact Name and Job Title Directorate & Speciality Lumbar Puncture Guidelines Jennifer Hallett, Nurse Practitioner Aquiline Chivinge, Sister Queen`s Day Case Unit MSKN, Neurosciences Date of submission November 2014 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Indications: a sample of cerebrospinal fluid (CSF) for diagnostic purposes. To measure the pressure of CSF and withdraw fluid in the treatment of benign intracranial hypertension. Introduce therapeutic agents; for example antibiotics or cytotoxic intrathecal chemotherapy (Dougherty & Lister 2011). Contraindications: Lumbar puncture is contraindicated where raised intracranial pressure is apparent or suspected Version Version 4 If this version supersedes another clinical guideline please be explicit about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a meta-analysis of randomised controlled trials 2b at least one randomised controlled trial 3a at least one well-designed controlled study without 3b randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (i.e. comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Version 3 1, 5 and 6 Yes Ward Sisters/Charge Nurses, PDMs, Clinical Leads, Matrons, Nursing Practice Guidelines Group (includes University of Nottingham representative), Clinical Quality, Risk and Safety Manager, Infection Prevention and Control Team. 1

Ratified by: Date: Target audience Review Date: (to be applied by the Integrated Governance Team) Matron s Forum November 2014 All Clinical Nursing Staff November 2019 A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date; however this must be managed through Directorate Governance processes. This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. 2

NOTTINGHAM UNIVERSITY HOSPITALS NURSING PRACTICE GUIDELINES LUMBAR PUNCTURE CONTENTS Introduction... 4 Contra-Indications... 5 Essential Equipment... 5 Pre Procedure... 6 Positioning... 7 Procedure... 9 Specimens... 11 Aftercare... 12 Best Practice... 14 Possible Complications Following Procedure... 15 Appendix 1 Checklist for the Review and Approval of Procedural Documents (to be used by authors and at the Matron s Forum)... 19 3

Introduction A lumbar puncture is performed to: Obtain a sample of cerebrospinal fluid (CSF) for diagnostic purposes. To measure the pressure of CSF and withdraw fluid in the treatment of benign intracranial hypertension. Introduce therapeutic agents; for example antibiotics or cytotoxic intrathecal chemotherapy (Dougherty & Lister 2011). Access to the CSF, which flows in the subarachnoid space, is gained via a hollow needle inserted into the lumbar cisterna through the third or fourth lumbar interspace (Dougherty & Lister 2011). The spinal cord normally terminates at the level of the first lumbar vertebra. Therefore the risk of neurological damage during lumbar puncture is reduced. The lumbar cisterna is an expanded area of the subarachnoid space containing more CSF so the success of the procedure is enhanced (Hickey 2008). 4

Contra-Indications Lumbar puncture is contraindicated where raised intracranial pressure is apparent or suspected. Therefore, nursing and medical assessment is essential prior to the procedure. A computer tomography (CT) scan of the brain is recommended as a first line of investigation whenever raised intracranial pressure is suspected, particularly in patients with suspected mass or space occupying lesions, since this may lead to herniation and coning (Waterhouse & Woodward 2009). In specialised neurological units however, CSF may be drained to relieve headache or prior to specialised surgery, when raised intracranial pressure is due to the build-up of CSF (Dougherty & Lister 2011). Other contraindications may include patients with thrombocytopenia and those receiving anticoagulation therapy (Dougherty & Lister 2011) Essential Equipment sterile dressing pack for lumbar puncture 1 x pair of sterile gloves Antiseptic skin cleansing agent (alcoholic betadine or chlorhexidine 0.5%) Sterile syringes 10ml A selection of different size hypodermic needles: gauge 18 (Pink), 20 (Yellow) and 22 (Black) Local anaesthetic (Lidocaine [Lignocaine] 1% and 2%) 3 x sterile universal specimen bottles labelled 1, 2 & 3 1 grey bottle (for glucose analysis), if necessary Disposable manometer ( NUH 2010) Sterile gauze wound dressing and sterile plaster 5

Sharps bin Pre Procedure PRINCIPLE RATIONALE a) The prospect of a lumbar puncture often seems to cause an inordinate amount of fear and anxiety in patients, therefore it is paramount to discuss and outline the procedure, providing patient information and gaining informed consent. Type of consent requires documentation. To reassure and provide support, to ensure that the patient understands the procedure and gives valid consent (NUH 2012, NMC 2008). b) Pre procedure analgesic should be discussed and administered according to patient preferences. Oral analgesics can reduce pain and fear induced by the administration of local anaesthetic that is administered by the Practitioner to the area prior to lumbar puncture. c) Encourage patients to empty their bladder prior to the procedure. To maximise patient comfort during the procedure. d) Another member of staff must be present when a patient is undergoing this procedure. Their role is a pivotal one in reassuring the patient. e) If drugs are being administered, the registered nurse must be Thorough checking is essential to prevent administration errors 6

involved in the checking process (NUH Medicines Management 2011) A separate protocol, which MUST be followed, exists for the administration of intrathecal cytotoxic drugs (NUH: Cytotoxic management 2010). This includes additional training requirements which need to be undertaken. occurring. f) Vital signs should be taken pre and post procedure. To obtain baseline observations, so clinical and physiological changes and deterioration are noted (NUH 2014). Positioning PRINCIPLE RATIONALE a) Patients are encouraged to wear loose clothing or theatre gowns. To enable access to the spine & to allow the doctor access for anatomical landmark positions. b) Lying: In the lateral position with the patient s back to the edge of the bed, head and neck flexed and knees drawn up to the chest (Figure 2). Support the patient in this position by holding him/her behind the shoulders. This ensures maximum widening of the intervertebral spaces, allowing easier access to the subarachnoid space (Dougherty & Lister 2011) 7

c) Sitting: Sitting upright, straddling a chair, with their back to the doctor; or some patients may be more comfortable sitting on the edge of the bed, resting their arms on a pillow placed on a bed table (which has brakes applied). Check with medical staff which position they would favour for the lumbar puncture. May be used for patients who are unable to maintain the lying position or with other problems e.g. breathlessness (Dougherty & Lister 2011) 8

Procedure PRINCIPLE RATIONALE a) This is an aseptic procedure performed under local anaesthetic undertaken by the doctor who will ensure adequate skin preparation and sterile field. Check and confirm with the patient for allergies to skin preparation materials. To reduce the risk of infection and to maintain comfort (Dept of Health 2007). To highlight patient allergies and prevent allergic incidences. b) The nurse checks the dose/percentage and expiry date of the (lignocaine) with the practitioner prior to administration. To prevent the risk of drug administration error (NUH Medicines Code of Practice 2011). c) Once anaesthesia is obtained the spinal needle is introduced into the intervertebral space, and the introducer is partly withdrawn to check if cerebrospinal fluid is present. To ascertain that the spinal needle is in the subarachnoid space (Lindsay et al 1997). d) A disposable manometer may be attached (NUH (2010) Documentation Control, ref; CL/CGP/035). To ascertain the pressure of the Cerebral-spinal fluid, normal range is 6-18cm H2O (Hickey 2008). e) If requested, the Queckenstedt manoeuvre may be performed. The Queckenstedt manoeuvre is when the nurse applies This is to check for CSF obstruction in the spinal canal. A free rise and fall of CSF may indicate that no obstruction is 9

transient pressure to the jugular vein on one side of the neck; and the rise and fall of the CSF is noted by the practitioner. present (Lindsay et al 1997). f) Samples of CSF are collected aseptically. Three samples are taken, ten drops in each numbered specimen bottle, plus a sample for glucose, if necessary. The presence of blood in the CSF may indicate a traumatic insertion of the spinal needle. The fluid should clear by the 3rd specimen (Lindsay et al 1997). If the patient has had a subarachnoid haemorrhage, the fluid may remain blood stained (Lindsay et al 1997). g) The spinal needle is removed and pressure applied over the puncture site for 1 to 2 minutes using a sterile gauze swab. To minimise bleeding and leakage of the CSF. The pathophysiology of post lumbar puncture headache is thought to develop from leakage of CSF through the dural puncture (Shah & Thomas 2007) h) A sterile plaster is applied to the puncture site and left in situ for 24 hours. To protect and prevent secondary infection (Dept of Health 2007) 10

Specimens PRINCIPLE RATIONAL a) The specimens must be sent to the appropriate laboratory within an hour, for example clinical chemistry and/or microbiology, depending on the type of tests ordered. It is primarily the doctor s responsibility to forward the specimens (NUH 2011, NUH 2012) The appropriate investigations must occur within 3 hours of collection of the specimen. Expert opinion states that organisms present may die after this time, giving false negative results (Hickey 2008). b) If the patient is thought to pose an infection risk, specimens may be required to be transported in a Bio-hazard bag. Contact Infection Control or Microbiology for advice and/or review Specimen Collection and Transportation guidelines (NUH 2013) To maintain the health and safety of employees & the public 11

Aftercare PRINCIPAL RATIONAL a) Assess and record the patient's condition following the procedure. This may include changes in neurological status, conscious level, blood pressure, pulse, respirations and change in sensation in legs. The Glasgow Coma Scale is a reliable indicator of adverse changes (Addison & Crawford 1999 and NUH 2014). To detect any adverse effect of the procedure and so that prompt action can be taken. b) Encourage the patient to have a short period of rest following the procedure (See Best Practice Box) A short period of rest is encouraged before mobilizing. c) If the patient experiences headache, administer analgesia as prescribed, (if not contraindicated), ask him/her to lie down, increase fluid intake and refer to medical staff, if appropriate (see Best Practice Box). d) Encourage the patient to drink plenty of fluids, 2 3 litres in 24 hours (Dougherty & Lister 2011) To replace any lost fluids. 12

e) Observe for any leakage from the puncture site. If excessive leakage occurs, refer to medical staff. Excessive may be defined as leakage through the plaster/dressing. To detect any adverse effect of the procedure and so that prompt action can be taken. Complications associated with lumbar puncture may include: infection, haemorrhage, herniation (in the presence of raised intracranial pressure), headache, backache, puncture site leakage and drug induced meninges irritation (Dougherty & Lister 2011). f) Record the procedure in the appropriate documents. To promote continuity of care and To provide an accurate record for future reference (NMC 2008) 13

Best Practice Best Practice Post lumbar Puncture Headache (PLPH) The frequency of PLPH varies widely among individuals and has been reported to occur in one third of patients (Raskin 2005), or occurs in approximately 1:4 patients (Waterhouse & Woodward 2009). Characteristically, the headache can start from 24-48 hours or 14 days after lumbar puncture (Shah & Thomas 2007). There is no evidence that bed rest for 4-6 hours post procedure will prevent headache (Waterhouse & Woodward 2009). Lying flat has been thought to reduce the incidence of PLPH following the procedure. However, there is insufficient evidence to warrant strict flat bed rest (Sudlow & Warlow, 2002). The aftercare of lumbar puncture should be individualised to the patients preference and needs. After a short period of rest from the procedure, patients should be allowed to manoeuvre themselves freely and if a headache develops which is relieved by lying flat /or down, then this should be encouraged. If not contraindicated, prescribed analgesia should be administered. No current evidence exists for the use of increased fluids in the prevention of PLPH (Sudlow & Warlow, 2002) and (Shah & Thomas 2007). However, patients should be advised not to become dehydrated and be offered adequate fluid intake to reduce the risk. Headache is thought to be related to low CSF volume, affecting CSF pressure as the fluid leaks into the surrounding tissues around the needle insertion site. There is convincing evidence that the incidence of PLPH is reduced if the direction of the bevel of the Quincke needle is inserted parallel to the longitudinal dural fibres rather than perpendicular thus separating the dural fibres rather than cutting them (Evans et al, 2000). Evans et al (2000) also suggest that the incidence of post lumbar puncture headache could be reduced if medical staff changed to non-cutting/ atraumatic spinal needles (e.g. the Whitacre or Sprotte design) for the procedure. 14

Possible Complications Following Procedure Change in level of consciousness. Infection and meningitis. Headache. CSF Leak. Spinal haemorrhage &/or haematoma. Nerve root irritation and low back pain. 15

References Addison, C and Crawford, B (1999) Not bad, just misunderstood Nursing Times Vol. 95, No. 43, pp. 52-55 Department of Health (2007) Saving Lives: reducing infection, delivering clean safe care (revised edition), London, Crown Copyright Dougherty, L & Lister, S. Ed (2011) The Royal Marsden of Clinical Nursing Procedures. 8th Edition Oxford: Wiley Blackwell. Evans R., Armon C., Frohman Elliot M. and Goodin Douglas S. (2000) Assessment: Prevention of post-lumbar puncture headaches: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. V55 N.o7 pp.909-914. This information is current as of April23, 2009: Source www.neurology.org/cgi/content/full/55/7/909 Hickey, J (2008). The Clinical Practice of Neurological and Neurosurgical Nursing. Sixth Edition. Lippincott Williams and Wilkins. Lindsay K W., Bone I., Callander R (1997). Neurology and Neurosurgery Illustrated. Third Edition. Churchill Livingstone National Patient Safety Agency. Fifth Edition (2007) Report written by: Professor Richard Thomsom, Director of Epidemiology and Research; Dagmar Luettel, Research Associate; Frances Healey, Patient Safety Manager and Sarah Scobie, Head of Observatory. PSO/5. Safer care for the acutely ill patient: learning from serious incidents. N.I.C.E (2007) Care of Acutely Ill Patients in Hospital, NICE July 2007. National Institute for Health & clinical Excellence. Source: www.nice.org.uk/cg050 Nottingham University Hospitals NHS Trust (2011) Working in New Ways Guidelines for Implementation. Nottingham: NUH. Nottingham University Hospitals NHS Trust (2011) Working in New Ways Expanding the Scope of Professional Practice. Nottingham: NUH. 16

Nottingham University Hospitals NHS Trust (2012) Consent to Examination or Treatment Policy. NUH Infection Prevention and Control Policy (2013) Nottingham: NUH Nottingham University Hospitals NHS Trust (2012) Request and Specimen Labelling Policy. Nottingham: NUH Nottingham University Hospitals NHS Trust (2013) Waste Handling and Management Policy Nottingham: NUH Nottingham University Hospitals NHS Trust (2011) Medicines Code of Practice. Nottingham: NUH Nottingham University Hospitals NHS Trust (2012) Blood Borne Virus Policy (Including Management of Inoculation, Sharps and Contamination Incidents). Nottingham: NUH Nottingham University Hospital (2010) Policy for the prescribing, administration and supply of cytotoxic chemotherapy for any indication, and other drugs requiring specialist handling Nottingham University Hospital (2014) Guidelines for performing and recording neurological observations in the adult patient. Nottingham University Hospitals (2010) Management of Patients who are Symptomatic or at-risk of having Creutzfeldt - Jakob disease or any Transmissible Spongiform.Encephalopathy Policy. Documentation Control, Ref: CL/CGP/035, Dec 2010 (Authors, Infection Prevention & Control Team) Nottingham University Hospitals (2011) Clinical guidelines/nursing Guidelines pertaining to the collection of specimens for investigation Specimen Collection and Transportation. Nursing & Midwifery Council (2008) The Code: Standards of conduct, performance & ethics for Nurses and midwives. Raskin NH. Headache. In: Kasper DL, editor. Harrison s Manual of Medicine. 16 th ED. New York: McGraw Hill: 2005: 85-94 Shah, P and Thomas, S (2007) Post Lumbar Puncture Headache. 17

Hospital Physician pp51-55. www.turner-white.com Source on 23rd April 2009 Sudlow, C and Warlow, C (2002) Posture and fluids for preventing post-dural puncture headache The Cochrane Database of Systematic Issue 2. Waterhouse, C & Woodward, S (2009) Oxford Handbook of Neuroscience Nursing. Author: Jennifer Hallett, Nurse Practitioner and Aquiline Chivinge, Sister Queen`s Day Case Unit (Based on 2011 procedure written by Gail Mackay) SUGGESTED AUDIT POINTS 1. Has prescribed analgesia been given prior to the procedure to prevent PLPH? 2. Have the specimens left the ward within an hour of the procedure? 3. Has a record of the patients' condition been made following the procedure? 4. Has the patient given their consent to the procedure based on information? 18

Appendix 1 Checklist for the Review and Approval of Procedural Documents (to be used by authors and at the Matron s Forum) This should be the very last Appendix following all the others in the document Title of document being reviewed: Author Yes/No NPGG Yes/No Comments 1. Title Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy or protocol? 2. Rationale Are reasons for development of the document stated? 3. Development Process Is the method described in brief? Are individuals involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 19

4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 5. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are local/organisational supporting documents referenced? 6. Approval Does the document identify which committee/group will approve it? If appropriate, have the Staff Side committee been consulted about the document? NO N/A 20

7. Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8. Document Control Does the document identify where it will be held? Have archiving arrangements for superseded documents been addressed? 9. Process for Monitoring Compliance Are there measurable standards or KPIs to support monitoring compliance of the document? Is there a plan to review or audit compliance with the document? 10. Review Date NO NO NPGG shared folder NUH Intranet Yes Is the review date identified? NO 5 years Is the frequency of review identified? If so, is it acceptable? NO Yes 21

11. Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation? 12. Policy Overview Group Approval Date 22