LUMBAR PUNCTURE NEONATAL CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. This guideline applies to all staff responsible for undertaking or assisting with a neonatal lumbar puncture. 2. Guidance. 2.1 Indications: - Routine investigation in the initial septic screen, to diagnose central nervous system infections including congenital infections, and bacterial and fungal infections. To drain CSF in communicating hydrocephalus associated with intraventricular haemorrhage. Contraindications: - Increased intracranial pressure (ICP) Uncorrected thrombocytopenia or bleeding diathesis Lumbosacral anomalies Cardiorespiratory instability which may be eacerbated by procedure. 2.2 Anatomy: The termination of the spinal cord relative to the spine changes during fetal development. Between 25 and 40 weeks gestation the cord termination gradually ascends from L4 to L2, this should be taken into account and the lower L4-L5 interspace used for significantly preterm babies to avoid possible cord penetration. L3-L4 can be used in term babies. Figure 1. Diagram illustrating the position for optimal needle insertion during a Lumbar Puncture. Vertebra Skin Cerebrospinal Fluid Spinal chord Needle Illustration: Kim Smith. Page 1 of 7
2.3 Prior to LP: Ensure verbal consent is documented, ensure all equipment is available, and take blood glucose for comparison with CSF glucose. Equipment: Sucrose analgesia, Sterile gown, Sterile gloves and pack, Unisept cleaning solution, LP needles (22 gauge), Cavilon swab to seal skin after procedure 3 standard silver specimen pots. 2.4 Procedure: Clean lumbar area with Unisept soaked gauze in enlarging circles to include the iliac crests. Allow to dry. Drape with sterile field under the baby and above. To find the L4/L5 space, palpate the two posterior iliac crests and a line running through them will pass in to the space. Fleion of the spine is probably the most important and yet most difficult part of performing the LP. Insert the needle in the midline in the desired interspace, advance the needle 1 to 1.5cm in term baby, remove the stylet and check for CSF. A change in resistance can often be felt as the needle passes through the ligamentum flavum and Dura. If advanced too far it will cross the space and hit the vertebrae, and may cause a bloody tap due to trauma. The LP needle should enter the skin, aimed at the umbilicus, and travel through the narrow gap towards the CSF, pointing the needle too caudally or cranially will again touch the vertebrae. Wait for fluid, collect 5-6 drops in each of 3 bottles. Insert stylet before withdrawing needle out. Apply gentle pressure with swab. Press Cavilon swab gently over puncture site for 5 to 10 seconds after procedure. If no CSF then rotate the needle to reorient the bevel, if still no fluid is obtained then replace the stylet, remove needle, and try one space above or below. Alternatively ask for senior support. Send samples to appropriate labs and if out of hours then bleep to inform them of pending samples. Figure2. Inserting the needle between Lumbar 4 and Lumbar 5 space Iliac crest L 4/5 space Illustration: Kim Smith Page 2 of 7
Monitoring compliance and effectiveness This part must provide information on the processes and methodology for monitoring compliance with, and effectiveness of, the policy using the table below. Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Key Changes to practice Dr. Paul Munyard Audit As dictated by audit findings Child Health Directorate Audit and Neonatal clinical Guidelines Group Dr. Paul Munyard. Consultant Paediatrician and Neonatologist. Required changes to practice will be identified and actioned within 3 months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders Equality and Diversity 1.2. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 1.3. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendi 2. Page 3 of 7
Appendi 1. Governance Information Document Title Date Issued/Approved: November 2015 Lumbar Puncture Neonatal Clinical Guideline Date Valid From: January 2016 Date Valid To: January 2019 Directorate / Department responsible (author/owner): Dr Munyard. Consultant Paediatrician and Neonatologist Contact details: (01872) 252667 Brief summary of contents This guideline outlines procedure for undertaking a neonatal Lumbar Puncture. Suggested Keywords: Target Audience Eecutive Director responsible for Policy: Neonatal. Infection Screen. Lumbar Puncture. LP. RCHT PCH CFT KCCG Eecutive director Date revised: 27:02:2015 This document replaces (eact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes New Document Neonatal Consultant approval. Child Health Directorate Audit. Neonatal Clinical Guidelines Group Sheena Wallace Name and Post Title of additional signatories Signature of Eecutive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key eternal standards Related Documents: Not Required {Original Copy Signed} Internet & Intranet Intranet Only Neonatal. Midwifery. Child Health. Clinical None None Macdonald, M.G.(Ed) (2013) Procedures in Page 4 of 7
Neonatology, Philadelphia, Lipincott, Williams & Wilkins. Rennie, J.M. (2005) Roberton s tetbook of Neonatology, Fourth Edition, Elsevier publications, Philadelphia. Training Need Identified? None Version Control Table Date Versio n No Summary of Changes Changes Made by (Name and Job Title) October 2015 V1.0 Initial Issue and Formatting. Author: Sarah Tabrett Formatter: Kim Smith. Staff Nurse. November 2015 Approval at Consultant led Neonatal Guidelines Meeting All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of epiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the epress permission of the author or their Line Manager. Page 5 of 7
Appendi 2. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Lumbar Puncture Neonatal Clinical Guideline Directorate and service area: Child and Is this a new or eisting Policy? New Womens Health. Neonatal Name of individual completing Telephone: (01872) 252667 assessment: Dr. Paul Munyard. 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* As above This guideline is aimed at clinical staff responsible for the undertaking a Neonatal Lumbar Puncture 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Audit Audit Patients. Staff No b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Eisting Evidence Age Page 6 of 7
Se (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Seual Orientation, Biseual, Gay, heteroseual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this ecludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. No 9. If you are not recommending a Full Impact assessment please eplain why. No area indicated Signature of policy developer / lead manager / director Dr Paul Munyard Date of completion and submission 14:01:2016 Names and signatures of members carrying out the Screening Assessment 1. 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Kim Smith Date 14:01:2016 Page 7 of 7