Procedure for performing a diagnostic lumbar puncture & administration of intrathecal therapy

A lumbar puncture with administration of intrathecal chemotherapy is a procedure that will be required for many patients treated within the haemato-oncology unit in the Royal Hospital for Children, Glasgow.  This SOP outlines the procedure of a lumbar puncture.  

A lumbar puncture which is performed solely for diagnostic purposes may be performed by any individual trained and deemed competent.

For patients receiving intrathecal chemotherapy it is essential that the related documentation is read and understood.  Administration of intrathecal chemotherapy should only be performed by those practitioners who are named on the intrathecal register.

• Schiehallion Haematology/Oncology Unit Policy for Administration of Intrathecal Chemotherapy (RHC-HAEM-ONC-013)
• Intrathecal SACT Assessment Questions (RHC-HAEM-ONC-015)
• Policy & Guidelines for the Safe Prescribing, Dispensing & Administration of SACT for Children, Teenagers & Young Adults under the Care of the Haematology/Oncology Team, RHC, Glasgow (Ward 2A/2B) (RHC-HAEM-ONC-014)
• Blood Transfusion in Children with Haem/Onc Disease & following HSCT (RHC-HAEM-ONC-001)

This procedure may only be performed unsupervised by a consultant, trainee or “non-consultant” career grade doctor who is on the intrathecal register, i.e. completed appropriate training and certification in the performance of this procedure (see Appendix 2 and 3 for training/retraining records for supervised medical staff).

The prescription, preparation, collection, administration and checking of intrathecal drugs must comply with the Directorate Policy for Administration of Intrathecal Chemotherapy and the Women & Children’s Directorate Medication Policy.

Intrathecal drugs can only be checked by a registered nurse who has completed appropriate training and certification (on the intrathecal register).

• Lumbar puncture needles
• 2mls sterile syringes (not Luer lock)
• 21G and 25G sterile needles
• Sterile dressing pack
• Chlorhexidine 0.5% in 70% alcohol solution with tint (ChloraPrep® 3mls skin cleaning applicator)
• 2% Lignocaine (if performed without general anaesthetic)
• Sterile gloves
• Skin plaster
• Sterile universal containers
• Intrathecal drug and prescription sheet

1. Explain the procedure to patient/carer and obtain consent as per Division guidelines.
   
   
2. Many children require to have a general anaesthetic to perform a lumbar puncture and administration of intrathecal chemotherapy. Others require sedation - please consult the guidelines pertaining to sedation.
   
   
3. It is the responsibility of the person performing the procedure to ensure that the procedure is required and is appropriate to that child. It is important that a check is made on a recent platelet count and for some patients, the coagulation screen. Please consult the relevant policy (Blood Transfusion in Children with Haematological / Oncological Disease and following Haemopoietic Stem Cell Transplant – YOR-HAEM-001) for guidance on the use of blood product support in this situation.
   
   
4. Position the child on their side, conventionally in the left lateral position and bend their knees up to their chest (Figure 1). Expose the area from the lower ribs to mid-buttock.
   
   
5. Open dressing pack onto clean trolley and using a non-touch technique drop the sterile gloves, cleaning solution and lumbar puncture needles into the sterile area of the pack. Cleaning solution is handed to the doctor carrying out the lumbar puncture, and disposed of in the bin. It should not go on the dressing pack.
   
   
6. Wash and dry hands following the 6 stages of hand hygiene.
   
   
7. Put on sterile gloves.
   
   
8. Put a sterile drape under the patient’s buttock leaving the spine exposed.
   
   
9. Use chlorhexidine solution and disinfect skin area around procedure site – do not place on trolley, dispose of directly (change gloves if chlorhexidine solution has contaminated them before proceeding).  Wait for chlorhexidine solution applied to skin to dry.  See Appendix 1 for more detailed guidance about skin preparation for lumbar puncture procedures.
   
   
10. Locate the space between the 3rd and 4th lumbar vertebrae. This space lies on a line joining the iliac crests (Figure 1).
    
    
    
    
    Figure 1: Site of lumbar puncture between 3rd and 4th vertebrae
    
    

    If the child is not having a general anaesthetic, draw up Lignocaine with a 21G needle and 2mls syringe.  A separate dressing pack with sterile needles and syringes is used if the patient needs local anaesthetic.  It is then disposed of and another dressing pack is used for the lumbar punctures needles.  The Lignocaine and lumbar punctures needles should not be on the same trolley.

11. Using a 25G needle infiltrate the skin overlying the 3rd – 4th interspace with local anaesthesia.
    NB: Remove local anaesthesia (lignocaine) needle and syringe (used for this procedure) from the trolley before proceeding with lumbar puncture.
    
    
12. With a finger from your left hand placed on the spine of L3, introduce the lumbar puncture needle and direct it in a slightly cranial direction keeping carefully to the midline (Figure 2). Resistance will be felt as the needle passes through the ligamentum flavum. The epidural space is crossed and the subarachnoid space entered a few millimetres deeper. The stilette is removed and CSF will appear in the needle hub.
    
    Figure 2: Correct needle angulation
    
    
13. Collect CSF into universal containers – 6-10 drops into each container. Number of containers depends on analyses required. Two specimens are required for ALL trial, 10 drops in each. For medulloblastoma- 30 drops are required.
    
    ADMINISTRATION OF INTRATHECAL CHEMOTHERAPY
    Person performing administration of intrathecal chemotherapy must be on the Intrathecal Register
    
    
14. Take syringe containing the drug for intrathecal administration and, prior to attachment; make one final visual and verbal check that the drug is correct and suitable for Intrathecal administration to the patient.
    
    
    • CORRECT DRUG
    • CORRECT ROUTE
    • CORRECT PATIENT
    • CORRECT TIME AND PLACE
    
    
15. Attach syringe to the lumbar puncture needle and inject drug slowly. Once procedure has been completed, remove the needle and apply pressure over the site with a sterile swab for 30sec and then place a plaster over the wound.
    
    
16. Ask the patient to lie supine for at least 1 hour following the procedure in order to minimise the risk of post lumbar puncture headache.

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For further information contact:

Dr Nicholas Heaney via Switchboard on 0141 201 000

Ratified by (via email):

This document is intended to inform the practice of oncologists, anaesthetists & anaesthetic assistants performing percutaneous neuraxial procedures

There has been some discussion in the medical literature about recent cases of adhesive arachnoiditis and the role of different skin prep solutions. Contamination of equipment with small droplets of cleaning solution has been implicated. The numbers of cases are small and it’s difficult to draw firm conclusions, however from the evidence available we can agree on some learning points from these case reports;

Do Not pour chlorhexidine in alcohol solution onto an epidural / spinal tray. This risks contamination of equipment with droplets from a splash.

Do Not spray chlorhexidine in alcohol anywhere near an uncovered epidural / spinal trolley. Keep trolleys covered  / well away from site being prepped.

Do Not put any swabs used for cleaning back on the trolley

Do always let the skin prep dry fully before touching the skin.

Do check gloves after prepping & if skin prep is on gloves, change before handling epidural  / spinal equipment

To adequately prep the skin you may:

Spray the skin with 0.5% chlorhexidine in alcohol (or ask assistant to do this for you)

Use a ‘chloraprep’ 2% chlorhexidine with alcohol swabstick

Chlorhexidine is a more effective skin preparation than Iodine solutions for these procedures

Further Information:

Bogod D. The sting in the tail: antisepsis and the neuraxis revisited. Editorial in Anaesthesia 67: 12, December 2012

Prepared by Dr Graham Bell on behalf of the Anaesthetic Advisory Group 5^th December 2012.

Medical staff training programme & Medical staff re-registration programme (pdf)