Preparing patient

By
Arif Muttaqin
Preparation
Pleural biopsy
Bronchoscopy
Peritoneal paracentesis
Liver biopsy
Lumbar puncture
Preparation
Preparation of:
Nurse
Patient
Room
Equipment
Preparation
Preparation of Nurse :
Knowledge
Anatomy and physiology
Procedural institutions

Skill :
Cognitive
Interpersonal
Psychomotor

Attitude
Professional

Preparation
Preparation of Patient :
Assessment:
Orders,
Cooperative levels.
Diagnostics.
Informed consent
Privacy
Physical
Position
Preparation
Preparation of Room :
Operation table
Temperature
Noise
Preparation
Preparation of Equipment:
Technical procedure
Procedural institutions
Patient


Pleural biopsy Preparation
Pleural biopsy Preparation
Definition:
The pleura is the membrane that lines
the lungs and chest cavity. A pleural
biopsy is the removal of pleural tissue
for examination and eventual diagnosis

Alternative Names:
Closed pleural biopsy; Needle biopsy of the
pleura
Purpose Pleural biopsy
Pleural biopsy is performed to differentiate
between benign (noncancerous) and
malignant (cancerous) disease, to
diagnose viral, fungal, or parasitic
diseases, and to identify a condition called
collagen vascular disease of the pleura.
It is also ordered when a chest x ray
indicates a pleural-based tumor, reaction,
or pleural thickness
Pleural biopsy Preparation
Preparations for this procedure vary,
depending on the type of procedure
requested.
Closed needle biopsy requires little or no
preparation.
Open pleural biopsy, which is performed in a
hospital, requires fasting (no solids or liquids)
for 8-12 hours before the procedure because
the stomach must be empty before general
anesthesia is administered.
Thoracentesis
Definition
A pleural biopsy is a procedure to remove a sample of the tissue
lining the lungs and the inside of the chest wall to check for
disease or infection.

Alternative Names
Closed pleural biopsy; Needle biopsy of the pleura

How the test is performed
This test does not have to be done in the hospital. It may be
done at a clinic or doctor's office.
Patient will be sitting up for the biopsy. The health care provider
will cleanse the skin at the biopsy site, and inject a local numbing
drug (anesthetic) through the skin and into the lining of the lungs
and chest wall (pleural membrane).
Thoracentesis Preparation
Thoracentesis (also referred to as Pleural
fluid aspiration or Pleural tap) is a
procedure to remove fluid from the space
between the lining of the outside of the
lungs (pleura) and the wall of the chest.
Normally, very little fluid is present in this
space. An accumulation of excess fluid
between the layers of the pleura is called a
pleural effusion.
THE THORACENTESIS
PROCEDURE
A small area of skin on Patientr chest or back is
washed with a sterilizing solution. Some
numbing medicine (local anesthetic) is injected
in this area.
A needle is then placed through the skin of the
chest wall into the space around the lungs called
the pleural space. Fluid is withdrawn and
collected and may be sent to a laboratory for
analysis (pleural fluid analysis).
In a pleural biopsy, a small piece of
pleural tissue in the chest is removed
with a needle. The biopsy may
distinguish between a cancerous and
noncancerous disease. It also can
help to detect whether a viral, fungal
or parasitic disease is present.
PREPARING FOR THE
PROCEDURE
No special preparation is needed before
the procedure. A chest x-ray is may be
performed before and after the test.
Do not cough, breathe deeply, or move
during the test to avoid injury to the lung.
DURING THE PROCEDURE
Patient will sit on the edge of a chair or bed with
Patient head and arms resting on a table. The
skin around the procedure site is disinfected and
the area is draped. A local anesthetic is injected
into the skin. The thoracentesis needle is
inserted above the rib into the pleural space.
There will be a stinging sensation when the local
anesthetic is injected, and Patient may feel a
sensation of pressure when the needle is
inserted into the pleural space.
Assess develop shortness of breath or chest
pain.
POTENTIAL RISKS
Pneumothorax (collapse of the lung)
Fluid re-accumulation
Pulmonary edema
Bleeding
Infection
Respiratory distress
open pleural biopsy
Definition
An open pleural biopsy is a procedure to
remove and examine the tissue that lines the
inside of the chest. This tissue is called the
pleura.

Alternative Names
Biopsy - open pleura
In an open pleural biopsy, a small piece of the pleural tissue is removed
through a surgical incision in the chest. After the sample is obtained, a
chest tube is placed and the incision is closed with stitches. Abnormal
results may indicate tuberculosis, abnormal growths, viral, fungal, and
parasitic diseases.
Bronchoscopy Preparation
RSUD Soetomo, 1994
Bronchoscopy
Definition
Bronchoscopy is a procedure in which a
hollow, flexible tube called a bronchoscope is
inserted into the airways through the nose or
mouth to provide a view of the
tracheobronchial tree. It can also be used to
collect bronchial and/or lung secretions and to
perform tissue biopsy.

Bronchoscopy
Purpose
During a bronchoscopy, the physician can
visually examine the lower airways, including
the larynx, trachea, bronchi, and bronchioles.
The procedure is used to examine the
mucosal surface of the airways for
abnormalities that might be associated with a
variety of lung diseases. Its use may be
diagnostic or therapeutic.

Bronchoscopy
Bronchoscopy may be used to examine and help diagnose:
diseases of the lung, such as cancer or tuberculosis
congenital deformity of the lungs
suspected tumor, obstruction, secretion, bleeding, or foreign body in the
airways
airway abnormalities, such as tracheal stenoses
persistent cough, or hemoptysis, that includes blood in the sputum
Bronchoscopy may also be used for the following therapeutic
purposes:
to remove a foreign body in the lungs
to remove excessive secretions
Bronchoscopy can also be used to collect the following biopsy
specimens:
sputum
tissue samples from the bronchi or bronchioles
cells collected from washing the lining of the bronchi or bronchioles
Bronchoscopy
If the purpose of the bronchoscopy is to take
tissue samples or biopsy, a forceps or
bronchial brush are used to obtain cells.
Alternatively, if the purpose is to identify an
infectious agent, a bronchoalveolar lavage
can be performed to gather fluid for culture
purposes. If any foreign matter is found in
the airways, it can be removed as well.

Bronchoscopy
The instrument used in bronchoscopy, a bronchoscope, is a slender,
flexible tube less than 0.5 in (2.5 cm) wide and approximately 2 ft
(0.3 m) long that uses fiberoptic technology (very fine filaments that
can bend and carry light). There are two types of bronchoscopes, a
standard tube that is more rigid and a fiberoptic tube that is more
flexible.
The rigid instrument does not bend, does not see as far down into
the lungs as the flexible one, and may carry a greater risk of causing
injury to nearby structures. Because it can cause more discomfort
than the flexible bronchoscope, it usually requires general
anesthesia. However, it is useful for taking large samples of tissue
and for removing foreign bodies from the airways.
During the procedure, the airway is never blocked since oxygen can
be supplied through the bronchoscope.

Bronchoscopy fiberoptics
Bronchoscopy is usually performed in an endoscopy room, but may
also be performed at the bedside. The patient is placed on his back
or sits upright. A pulmonologist, a specialist trained to perform the
procedure, sprays an anesthetic into the patient's mouth or throat.
When anesthesia has taken effect and the area is numb, the
bronchoscope is inserted into the patient's mouth and passed into
the throat. If the bronchoscope is passed through the nose, an
anesthetic jelly is inserted into one nostril. While the bronchoscope
is moving down the throat, additional anesthetic is put into the
bronchoscope to anesthetize the lower airways.
The physician observes the trachea, bronchi, and the mucosal lining
of these passageways looking for any abnormalities that may be
present. If samples are needed, a bronchial lavage may be
performed, meaning that a saline solution is introduced to flush the
area prior to collecting cells for laboratory analysis. Very small
brushes, needles, or forceps may also be introduced through the
bronchoscope to collect tissue samples from the lungs.
Bronchoscopy can be performed via the patient's mouth (A) or through the nose (C).
During the procedure, the scope is fed down the trachea and into the bronchus leading
to the lungs (B), providing the physician with a view of internal structures (D).
Bronchoscopy Preparation
The patient should fast for six to 12 hours prior to the procedure and
refrain from drinking any liquids the day of the procedure.
Smoking should be avoided for 24 hours prior to the procedure and
patients should also avoid taking any aspirin or ibuprofen-type
medications.
The bronchoscopy itself takes about 4560 minutes. Prior to the
bronchoscopy, several tests are usually done, including a chest x
ray and blood work.
Sometimes a bronchoscopy is done under general anesthesia, in
which case the patient will have an intravenous (IV) line in the arm.
More commonly, the procedure is performed under local anesthesia,
which is sprayed into the nose or mouth. This is necessary to inhibit
the gag reflex. A sedative also may be given. A signed consent form
is necessary for this procedure.

Bronchoscopy Preparation
Purpose
During a bronchoscopy, the physician can
visually examine the lower airways, including
the larynx, trachea, bronchi, and bronchioles.
The procedure is used to examine the
mucosal surface of the airways for
abnormalities that might be associated with a
variety of lung diseases. Its use may be
diagnostic or therapeutic.

Aftercare Bronchoscopy
After the bronchoscopy, the vital signs (heart rate, blood pressure,
and breathing) are monitored. Sometimes patients have an
abnormal reaction to anesthesia. Any sputum should be collected in
an emesis basin so that it can be examined for the presence of
blood.
If a biopsy was taken, the patient should not cough or clear the
throat as this might dislodge any blood clot that has formed and
cause bleeding. No food or drink should be consumed for about two
hours after the procedure or until the anesthesia wears off.
There is a significant risk for choking if anything (including water) is
ingested before the anesthetic wears off, and the gag reflex has
returned. To test if the gag reflex has returned, a spoon is placed on
the back of the tongue for a few seconds with light pressure. If there
is no gagging, the process is repeated after 15 minutes.
The gag reflex should return in one to two hours. Ice chips or clear
liquids should be taken before the patient attempts to eat solid food.
Aftercare Bronchoscopy
Patients are informed that after the anesthetic
wears off the throat may be irritated for several
days.
Patients should notify their health care provider if
they develop any of these symptoms:
hemoptysis (coughing up blood)
shortness of breath, wheezing, or any trouble
breathing
chest pain
fever, with or without breathing problems
Risks
Use of the bronchoscope mildly irritates the
lining of the airways, resulting in some swelling
and inflammation, as well as hoarseness caused
from abrading the vocal cords. If this abrasion is
more serious, it can lead to respiratory difficulty
or bleeding of the lining of the airways.
The bronchoscopy procedure is also associated
with a small risk of disordered heart rhythm
(arrhythmia), heart attacks, low blood oxygen
(hypoxemia), and pneumothorax (a puncture of
the lungs that allows air to escape into the space
between the lung and the chest wall).
Risks
These risks are greater with the use of a rigid bronchoscope than
with a fiberoptic bronchoscope. If a rigid tube is used, there is also a
risk of chipped teeth. The risk of transmitting infectious disease from
one patient to another by the bronchoscope is also present.
There is also a risk of infection from endoscopes inadequately
reprocessed by the automated endoscope reprocessing (AER)
system. The Centers for Disease Control (CDC) reported cases of
patient-to-patient transmission of infections following bronchoscopic
procedures using bronchoscopes that were inadequately
reprocessed by AERs.
Investigation of the incidents revealed inconsistencies between the
reprocessing instructions provided by the manufacturer of the
bronchoscope and the manufacturer of the AER; or that the
bronchoscopes were inadequately reprocessed.
Normal results
If the results of the bronchoscopy are normal, the windpipe (trachea)
appears as smooth muscle with C-shaped rings of cartilage at
regular intervals. There are no abnormalities either in the trachea or
in the bronchi of the lungs.
Bronchoscopy results may also confirm a suspected diagnosis. This
may include swelling, ulceration, or deformity in the bronchial wall,
such as inflammation, stenosis, or compression of the trachea,
neoplasm, and foreign bodies. The bronchoscopy may also reveal
the presence of atypical substances in the trachea and bronchi. If
samples are taken, the results could indicate cancer, disease-
causing agents, or other lung diseases. Other findings may include
constriction or narrowing (stenosis), compression, dilation of
vessels, or abnormal branching of the bronchi. Abnormal
substances that might be found in the airways include blood,
secretions, or mucous plugs.
Peritoneal paracentesis
Introduction
Paracentesis is a
procedure in which
a needle or
catheter is inserted
into the peritoneal
cavity to obtain
ascitic fluid for
diagnostic or
therapeutic
purposes
Indications
Diagnostic:
New onset ascites:
To determine aetiology.
To differentiate transudate versus exudate.
To detect cancerous cells.
Suspected spontaneous or secondary bacterial
peritonitis
Therapeutic:
To relieve respiratory distress secondary to ascites.
To relieve abdominal pain or pressure secondary to
ascites.

Contraindications
Uncooperative patient
Skin infection at the proposed puncture
site
Pregnancy
Severe bowel distension
Coagulopathy (opinion divided - some feel
only precluded where there is clinically
evident fibrinolysis or DIC)

Equipment
The equipment required can be found in a disposable
paracentesis/thoracentesis kit. It includes the following:
Antiseptic swab sticks
Fenestrated drape
Lidocaine 1%, 5-mL ampule
Syringe, 10 mL
Injection needles, 22 gauge (ga), 2
Injection needle, 25 ga
Scalpel, No. 11 blade
Catheter, 8F, over 18 ga x 7 1/2" needle with 3-way stopcock, self-sealing valve,
and a 5-mL Luer-Lock syringe
Syringe, 60 mL
Introducer needle, 20 ga
Tubing set with roller clamp
Drainage bag or vacuum container
Specimen vials or collection bottles, 3
Gauze, 4 X 4 inch
Adhesive dressing
Positioning
The two recommended areas of abdominal wall entry for
paracentesis are as follows (see photo):
Two centimeters below the umbilicus in the midline (through the
linea alba)
Five centimeters superior and medial to the anterior superior iliac
spines on either side
The authors recommend the routine use of
ultrasonography to verify the presence of a fluid pocket
under the selected entry site in order to increase the rate
of success.6 The ultrasound also helps the practitioner
avoid a distended urinary bladder or small bowel
adhesions below the selected entry point. To minimize
complications, avoid areas of prominent veins (caput
medusa), infected skin, or scar tissue.
Technique
Explain the procedure, benefits, risks,
complications, and alternative options to
the patient or the patient's representative
and obtain signed informed consent.
Empty the patient's bladder, either
voluntarily or with a Foley catheter.
Position the patient and prepare the skin
around the entry site with an antiseptic
solution.

Technique
Explain the procedure,
benefits, risks, complications,
and alternative options to the
patient or the patient's
representative and obtain
signed informed consent.
Empty the patient's bladder,
either voluntarily or with a
Foley catheter.
Position the patient and
prepare the skin around the
entry site with an antiseptic
solution.

Technique
Apply a sterile fenestrated drape
to create a sterile field.
Use the 5-mL syringe and the 25-
ga needle to raise a small
lidocaine skin wheal around the
skin entry site.
Switch to the longer 20-ga needle
and administer 4-5 mL of
lidocaine along the catheter
insertion tract. Make sure to
anesthetize all the way down to
the peritoneum. The authors
recommend alternating injection
and intermittent aspiration down
the tract until ascitic fluid is
noticed in the syringe. Note the
depth at which the peritoneum is
entered. In obese patients,
reaching the peritoneum may
involve passing through a
significant amount of adipose
tissue.
Technique
Use the No. 11 scalpel blade
to make a small nick in the
skin to allow an easier
catheter passage.
Insert the needle directly
perpendicular to the selected
skin entry point. Slow
insertion in increments of 5
mm is preferred to minimize
the risk of inadvertent
vascular entry or puncture of
the small bowel.
Technique
Continuously apply negative pressure to the syringe as the needle is
advanced. Upon entry to the peritoneal cavity, loss of resistance is felt
and ascitic fluid can be seen filling the syringe. At this point, advance
the device 2-5 mm into the peritoneal cavity to prevent misplacement
during catheter advancement. In general, avoid advancing the needle
deeper than the safety mark that is present on most commercially
available catheters or deeper than 1 cm beyond the depth at which
ascitic fluid was noticed in the lidocaine syringe.
Technique
Use one hand to firmly anchor the
needle and syringe securely in place to
prevent the needle from entering
further into the peritoneal cavity.
Use the other hand to hold the
stopcock and catheter and advance
the catheter over the needle and into
the peritoneal cavity all the way to the
skin. If any resistance is noticed, the
catheter was probably misplaced into
the subcutaneous tissue. If this is the
case, withdraw the device completely
and reattempt insertion. When
withdrawing the device, always remove
the needle and catheter together as a
unit in order to prevent the bevel from
cutting the catheter.
Technique
While holding the stopcock,
pull the needle out. The self-
sealing valve prevents fluid
leak.
Attach the 60-mL syringe to
the 3-way stopcock and
aspirate to obtain ascitic fluid
and distribute it to the
specimen vials. Use the 3-
way valve, as needed, to
control fluid flow and prevent
leakage when no syringe or
tubing is attached.
Technique
Connect one end of
the fluid collection
tubing to the stopcock
and the other end to a
vacuum bottle or a
drainage bag.
Technique
The catheter can become occluded
by a loop of bowel or omentum. If
the flow stops, kink or clap the
tubing to avert loss of suction, then
break the seal and manipulate the
catheter slightly, then reconnect
and see if flow resumes. Rotating
the catheter about the long axis
can sometimes reinstitute flow in
models with side ports.
Remove the catheter after the
desired amount of ascitic fluid has
been drained. Apply firm pressure,
as necessary, to stop bleeding, if
present. Place a bandage over the
skin puncture site.
Liver biopsy
By
Arif Muttaqin
Liver Biopsy
A liver biopsy is not a routine procedure, but is performed when it
is necessary to determine the presence of liver disease and to
look for malignancy, cysts, parasites, or other pathology. The
actual procedure is only slightly uncomfortable. Most of the
discomfort arises from being required to lie still for several hours
afterwards to prevent bleeding from the biopsy site.
Definition
The liver is a pyramid-shaped organ that lies within the upper right
side of the abdomen. In a typical liver biopsy, a needle is inserted
through the rib cage or abdominal wall and into the liver to obtain a
sample for examination.
The procedure can also be performed by inserting a needle into the
jugular vein in the neck and passing a catheter through the veins down
to the liver to obtain the sample.
The biopsy helps diagnose a number of liver diseases. The biopsy
also helps in the assessment of the stage (early, advanced) of the liver
disease. This is especially important in hepatitis C infection.
The biopsy also helps detect:
cancer
infections
the cause of an unexplained enlargement of the liver
abnormal liver enzymes that have been detected in blood tests

Core Assessment
drug allergies
medications
bleeding problems
pregnant

Lumbar puncture
Lumbar puncture
Lumbar puncture is a
procedure that is often
performed in the emergency
department to obtain
information about the
cerebrospinal fluid (CSF)
Although usually used for
diagnostic purposes to rule out
potential life-threatening
conditions such as bacterial
meningitis or subarachnoid
hemorrhage, lumbar puncture
is also sometimes performed
for therapeutic reasons, such
as the treatment of
pseudotumor cerebri.
Lumbar puncture
CSF fluid analysis can also aid
in the diagnosis of various
other conditions, such as
demyelinating diseases and
carcinomatous meningitis.
Lumbar puncture should be
performed only after a
neurological examination and
should never delay potentially
lifesaving interventions such
as the administration of
antibiotics and steroids to
patients with suspected
bacterial meningitis.
Indications
Suspicion of meningitis
Suspicion of subarachnoid hemorrhage
Suspicion of central nervous system
diseases such as Guillain-Barr
syndrome3 and carcinomatous meningitis
Therapeutic relief of pseudotumor cerebri

Contraindications
Absolute contraindications to lumbar puncture are as follows:

Unequal pressures between the supratentorial and infratentorial compartments, usually inferred
by characteristic findings on the brain CT scan:
Midline shift
Loss of suprachiasmatic and basilar cisterns
Posterior fossa mass
Loss of the superior cerebellar cistern
Loss of the quadrigeminal plate cistern
Infected skin over the needle entry site
Relative contraindications to lumbar puncture are as follows:
Increased intracranial pressure (ICP)
Coagulopathy
Brain abscess
Indications for brain CT scan prior to lumbar puncture include the following:4
Patients who are older than 60 years
Patients who are immunocompromised
Patients with known CNS lesions
Patients who have had a seizure within 1 week of presentation
Patients with abnormal level of consciousness
Patients with focal findings on neurological examination
Patients with papilledema seen on physical examination with clinical suspicion of elevated ICP

Prepare
Lumbar puncture, commonly called a spinal tap, is the
most common method. The test is usually done like this:
The patient lies on his or her side, with knees pulled up toward
the chest, and chin tucked downward. Sometimes the test is
done with the person sitting up, but bent forward.
After the back is cleaned, the health care provider will inject a
local numbing medicine (anesthetic) into the lower spine.
A spinal needle is inserted, usually into the lower back area.
Once the needle is properly positioned, CSF pressure is
measured and a sample is collected.
The needle is removed, the area is cleaned, and a bandage is
placed over the needle site. The person is often asked to lie
down for a short time after the test.
Prepare
Occasionally, special x-rays are used to help guide the needle into the
proper position. This is called fluoroscopy.
Lumbar puncture with fluid collection may also be part of other procedures,
particularly a myelogram (x-ray or CT scan after dye has been inserted into
the CSF).
Alternative methods of CSF collection are rarely used, but may be
necessary if the person has a back deformity or an infection.
Cisternal puncture uses a needle placed below the occipital bone (back of
the skull). It can be dangerous because it is so close to the brain stem. It is
always done with fluoroscopy.
Ventricular puncture is even more rare, but may be recommended in people
with possible brain herniation. This test is usually done in the operating
room. A hole is drilled in the skull, and a needle is inserted directly into one
of brain's ventricles.
CSF may also be collected from a tube that's already placed in the fluid,
such as a shunt or a venitricular drain. These sorts of tubes are usually
placed in the intensive care unit.
Prepare for the Test
The patient (or guardian) must give the
health care team permission to do the test.
Afterward, you should plan to rest for
several hours, even if you feel fine. You
won't be required to lie flat on your back
the entire time, but rest is advised to
prevent additional leakage of CSF around
the site of the puncture.
Risks

Risks of lumbar puncture include:
Bleeding into the spinal canal
Discomfort during the test
Headache after the test
Hypersensitivity (allergic) reaction to the anesthetic
Infection introduced by the needle going through the skin
There is an increased risk of bleeding in people who take blood
thinners.
Brain herniation may occur if this test is done on a person with a mass
in the brain (such as a tumor or abscess). This can result in brain
damage or death. This test is not done if an exam or test reveals signs
of a brain mass.
Damage to the nerves in the spinal cord may occur, particularly if the
person moves during the test.
Cisternal puncture or ventricular puncture carry additional risks of brain
or spinal cord damage and bleeding within the brain.
Instructions for Patients
Basic Instructions
Please arrange for a ride home after your lumbar puncture.
Drink extra fluids the day before
No solid foods from midnight on, if lumbar puncture is scheduled for the
morning.
Drink extra fluids (no caffeine) up to 2 hours before exam.
2 hours before exam NPO (If medications needed, take only with
swallow of water.)
Please arrive 45 minutes before scheduled lumbar puncture
appointment. Go to the
Lobby Registration office first then report to the 2nd floor Outpatient
Department.
Plan on 2 to 3 hours from arrival to discharge.
On the ride home, the back of the seat should be in the full reclining
position rather
than straight up. It is important to lie as flat as possible to help prevent a
bad headache.

Equipment
Spinal or lumbar puncture tray (including the items listed below)
Sterile gloves
Antiseptic solution with skin swabs
Sterile drape
Lidocaine 1% without epinephrine
Syringe, 3 mL
Needles, 20 and 25 gauge (ga)
Spinal needles, 20 and 22 ga
Three-way stopcock
Manometer
Four plastic test tubes, numbered 1-4, with caps
Sterile dressing
Optional: Syringe, 10 mL

Lumbar puncture lateral
recumbent position.

Positioning
Position the patient
in the lateral
recumbent position
with hips, knees,
and chin flexed
toward the chest in
order to open the
interlaminar spaces.
A pillow can be used
to support the head.
Positioning
The sitting position may
be a helpful alternative
position, especially in
obese patients (easier
to confirm the midline).
In order to open the
interlaminar spaces, the
patient should lean
forward and be
supported by a Mayo
stand with a pillow on it,
by hunching over the
back of a stool, or by
another person.
Lumbar puncture sitting position.

Technique
Explain the procedure, benefits,
risks, complications, and alternative
options to the patient or the patient's
representative and obtain a signed
informed consent.
Wearing nonsterile gloves, locate
the L3-L4 interspace by palpating
the right and left posterior superior
iliac crests and moving the fingers
medially toward the spine. Palpate
that interspace (L3-L4) as well as
one above (L2-L3) and one below
(L4-L5) to find the widest space.
Mark the entry site with a thumbnail
or a marker. To help open the
interlaminar spaces, the patient can
be asked to practice pushing the
entry site area out toward the
practitioner.
L3-L4 interspace palpation.
Technique
Open the spinal tray,
change to sterile
gloves, and prepare the
equipment. Open the
numbered plastic tubes
and place them upright,
assemble the stopcock
on the manometer, and
draw the lidocaine into
the 10-mL syringe.
Technique
Use the skin swabs and antiseptic solution to clean
the skin in a circular fashion starting at the L3-L4
interspace and moving outward to include at least
1 interspace above and below. Just before
applying the skin swabs, warn the patient that the
solution is very cold, since this can be unnerving to
the patient.
Place a sterile drape below the patient and a
fenestrated drape on the patient. Most spinal trays
contain fenestrated drapes with an adhesive tape
that keeps the drape in place.
Technique
Use the 10-mL syringe to administer local anesthesia. Raise a
skin wheal using the 25-ga needle and then switch to the longer
20-ga needle to anesthetize the deeper tissue. Insert the needle
all the way to the hub, aspirate to confirm that the needle is not in
a blood vessel, and then inject a small amount as the needle is
withdrawn a few centimeters. Continue this process above,
below, and to the sides very slightly (using the same puncture
site).

This process anesthetizes the entire immediate area so that, if
redirection of the spinal needle is necessary, the area will still be
anesthetized. For this reason, a 10-mL syringe may be more
beneficial than the usual 3-mL syringe supplied with the standard
lumbar puncture kit. The 20-ga needle can also be used as a
guide for the general direction of the spinal needle. In other
words, the best direction in which to aim the spinal needle can be
confirmed if the 20-ga needle encounters bone in one direction
but not in another.
Technique
Stabilize the needle (20 or 22 ga) with the index fingers and
advance it through the skin wheal using the thumbs. Orient the bevel
parallel to the longitudinal dural fibers to increase the chances of the
needle separating the fibers rather than cutting them (bevel facing
up in the lateral recumbent position and facing to either side in the
sitting position).
Insert the needle at a slightly cephalad angle toward the umbilicus.
Advance the needle slowly but smoothly. Occasionally, the
practitioner feels a characteristic "pop" when the needle penetrates
the dura. Otherwise, the stylet should be withdrawn after
approximately 4-5 cm and observed for fluid return. If no fluid
returns, replace the stylet, advance or withdraw the needle a few
millimeters, and recheck for fluid return. Continue this process until
fluid is successfully returned.
Technique
To measure the opening pressure, the patient must be in
the lateral recumbent position. After fluid returns from the
needle, attach the manometer through the stopcock and
note the height of the fluid column. The patient's legs
should be straightened when measuring open pressure
or a falsely elevated pressure will be obtained.
Collect at least 10 drops of CSF in each of the 4 plastic
tubes, starting with tube #1. The CSF that is in the
manometer should be used (if possible) for tube #1.
Replace the stylet and remove the needle. Clean off the
skin preparatory solution. Apply a sterile dressing and
place the patient in the supine position.
Pearls
If the patient is dehydrated, a falsely negative dry tap may be
obtained as a result of very low CSF volume and pressure. If this is
suspected, attempt to rehydrate the patient prior to the procedure.
If the procedure is performed in the sitting position and an opening
pressure is required (eg, pseudotumor cerebri), replace the stylet
and have an assistant help the patient into the left lateral recumbent
position. No data suggest increased risk of spinal headache or
transection of the spinal nerves with position change. Take care not
to change the orientation of the spinal needle during this maneuver.
The amount of lidocaine provided in most kits is often inadequate.
The authors recommend supplementing the kit with a 10-mL syringe
and a bottle of 1% lidocaine. Make sure not to exceed the maximal
recommend dose of 4.5 mg/kg of lidocaine. A smaller (27 ga, 1 1/4")
needle may be used for infiltration. Smaller needles are shown to be
associated with less pain during local anesthesia.
Pearls
If the CSF flow is too slow, ask the patient to cough or bear down as in the
Valsalva maneuver, or ask an assistant to intermittently press on the
patients abdomen to increase the flow. Alternatively, the needle can be
rotated 90 degrees such that the bevel faces cephalad.
Never delay intravenous antibiotics for a lumbar puncture or a pre-lumbar
puncture CT scan. Meningitis can usually be inferred from the cell count,
antigen detection, or both.
The smaller the needle used for the lumbar puncture, the lower the risk
of the patient developing a postlumbar puncture headache. Data suggest a
inverse linear relationship to gauge, and the authors recommend using a
22-ga needle, regardless of what size needle is supplied with the kit.5
The use of atraumatic needles has been shown to significantly reduce the
incidence of post lumbar puncture headache (3%) when compared to
standard spinal needles (approximately 30%).6,7 Obtaining pressures can
be more difficult with these needles.
Prophylactic bed rest following lumbar puncture has not been shown to be
of benefit and should not be recommended.8,9,10