Chapter 16 Lumbar puncture
INTRODUCTION
RATIONALE
Lumbar puncture is performed to:
Health benefits include the speedy diagnosis and treatment of meningitis, and investigations for other neurological disease and treatments for oncology patients. While we consider the risks and complications of the procedure, it is worth noting that the benefits to health outweigh the possible side-effects in nearly all cases (Kneen et al 2002).
ADMINISTRATION OF INTRATHECAL DRUGS
Readers should look at the most recent guidance on the Department of Health website (www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Healthservicecirculars/DH_086870). This guidance, ‘Health Service Circular HSC 2008/001’ is the basis for every Trust’s policy on intrathecal chemotherapy administration and specifies which hospital staff are allowed to participate in the prescribing preparation, delivery checking and administration of intrathecal drugs (DoH 2008). All staff involved have to undertake an agreed training programme and be added to a Trust Intrathecal Register for their role in intrathecal chemotherapy. All hospital personnel who are not on one of these registers are not allowed to undertake any practice relating to intrathecal chemotherapy. Although drugs are occasionally administered via this route in specialities other than oncology, there is less regulation, and anyone involved in this is recommended to read the guidance for chemotherapy as a measure of good practice.
PREPARATION OF THE CHILD AND FAMILY
It is vital to prepare both the child and family, as this will help to:
A full explanation of the reasons for performing the lumbar puncture including benefits to health, potential complications and risks, must be given. This should be at an age-appropriate level so the child and family can fully understand. This information can also be supported with written information leaflets or information available on websites such as (Patient UK at: www.patient.co.uk). The sharing of information is emphasised in the NSF (2004) Standard 3 and Standard 4 which state that the child and family should receive information about diagnosis, treatments and services available to them.
Parents may wish to stay with their child during the procedure, and may help to reassure the child by talking, holding hands or head stroking. Optimising the parents’ role reduces the child’s anxiety during the procedure. Staff should be sensitive to parents who are unable to provide this support (Mackenzie 2006). Nurses should promote an environment that encourages full parental involvement as the benefits to the child are well documented (Dudley & Carr 2004).
Preparing the child for the procedure through the use of play is also well documented. This is beneficial, particularly for children who have to undergo repeated procedures, such as the child with leukaemia (Broome et al 1990).
The healthcare professional performing the lumbar puncture should obtain consent from both the parents and child as appropriate (DoH 2001b). This consent will also involve a discussion of options for analgesia and sedation appropriate to the clinical situation. A child who requires routine and repeated lumbar puncture will be given the option to have the procedure under general anaesthesia or sedation with local anaesthetic (Gajjar et al 2000).
Conscious sedation with local anaesthetic combined with psychological or behavioural techniques are also used (Pederson 1996). In an acute setting when a lumbar puncture needs to be carried out in a timely and safe manner, a topical anaesthetic followed by an injected anaesthetic is recommended (Ellenby et al 2006). The nurse can play a vital role in supporting both child and parent through this procedure: to hold the child and to assist the doctor in obtaining spinal fluid under aseptic technique.
RISKS AND COMPLICATIONS
Lumbar puncture is indicated for both diagnostic and therapeutic reasons. A nurse should have a knowledge of the indications and contraindications to performing a lumbar puncture, and also an understanding of the procedural technique and risks. The risks, although rare, can be potentially life-threatening. These risks can be minimised by following the correct procedural and post-procedural care (Ellenby et al 2006).
Pain distress and anxiety
Pain distress and anxiety will be interpreted and experienced differently between each child and family. These effects can be minimised by promoting parents to support and comfort their child throughout the procedure. The relationship between non-essential touch and children’s distress during lumbar puncture has been clearly identified (Vannorsdall et al 2004). Gentle stroking, holding hands and touch can contribute to a safe and successful lumbar puncture.
Pederson (1996) also identified the effects of promoting non-pharmacological techniques (e.g. using distraction focusing on breathing, relaxation techniques and the use of imagery) with children during lumbar puncture. In an observational study, less verbal expressions of fear and resistance were reported as well as less muscular rigidity and less reports of post-procedural pain.
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