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Time to successful completion of simulated pediatric lumbar puncture in lateral vs seated position: Comparison in novice providers

Published:April 07, 2018DOI:https://doi.org/10.1016/j.ajem.2018.04.011
      Pediatric LP is a difficult procedure with a high failure rate, often due to lack of provider experience [
      • Pruden C.M.
      • Kerrey B.T.
      • Mittiga M.
      • Del Rey J.G.
      Procedural readiness of pediatric interns: defining novice performance through simulation.
      ,
      • Srivastava G.
      • Roddy M.
      • Langsam D.
      • Agrawal D.
      An educational video improves technique in performance of pediatric lumbar punctures.
      ]. Multiple attempts are often associated with patient discomfort and may complicate cerebral spinal fluid (CSF) interpretation [
      • Nigrovic L.E.
      • Kuppermann N.
      • Neuman M.I.
      Risk factors for traumatic or unsuccessful lumbar punctures in children.
      ]. Unlike adult LPs, obesity is not often the etiology of procedural difficulty. Pediatric LPs often require a more acute angle than adults, which also may contribute to novice failure rates [
      • Bruccoleri R.E.
      • Chen L.
      Needle-entry angle for lumbar puncture in children as determined by using ultrasonography.
      ]. The sitting position does present some theoretical advantage as the width of the subarachnoid space is significantly greater when infants are seated rather than lateral. The seated position may also be better tolerated and potentially safer [
      • Gleason C.A.
      • Martin R.J.
      • Anderson J.V.
      • Carlo W.A.
      • Sanniti K.J.
      • Fanaroff A.A.
      Optimal position for a spinal tap in preterm infants.
      ,
      • Weisman L.E.
      • Merenstein G.B.
      • Steenbarger J.R.
      The effect of lumbar puncture position in sick neonates.
      ] as infant's experience (see Table 1, Table 2)fewer respiratory complications while seated [
      • Gleason C.A.
      • Martin R.J.
      • Anderson J.V.
      • Carlo W.A.
      • Sanniti K.J.
      • Fanaroff A.A.
      Optimal position for a spinal tap in preterm infants.
      ]. Providers may also be more likely to obtain CSF on the first attempt in the seated position [
      • Hanson A.L.
      • Ros S.
      • Soprano J.
      Analysis of infant lumbar puncture success rates: sitting flexed versus lateral flexed positions.
      ,
      • Molina A.
      • Fons J.
      Factors associated with lumbar puncture success.
      ]. Despite these potential benefits, the lateral position is more often selected by providers [
      • Nigrovic L.E.
      • Kuppermann N.
      • Neuman M.I.
      Risk factors for traumatic or unsuccessful lumbar punctures in children.
      ,
      • Molina A.
      • Fons J.
      Factors associated with lumbar puncture success.
      ]. While previous work with simulation training has shown improvement in pediatric LP success rates in the clinical setting after training, the ideal initial approach in the pediatric patient is unclear [
      • Kessler D.O.
      • Auerbach M.
      • Pusic M.
      • Tunik M.G.
      • Foltin J.C.
      A randomized trial of simulation-based deliberate practice for infant lumbar puncture skills.
      ].
      Table 1Demographic of study participants.
      Age – mean (SD), years 24.4 (2.9)
      Sex – male, n (%) 14 (56)
      Experience – year of medical school n (%)
       1 17 (68)
       2 8 (32)
      Table 2Lumbar puncture outcomes by position.
      Sitting

      N = 25
      Lateral

      N = 24
      p-Value
      Median time, in seconds, spent performing LP (IQR) 214 (51–300) 52.5 (17–288.5) 0.193
      Successful LP (%) 18 (72) 18 (75) 0.812
      Median time, in seconds, to successful completion (IQR) 105.5 (33–240) 30 (14–78) 0.096
      Median number of attempts (IQR) 4 (2−10) 2 (1–9) 0.448
      First attempt success

      (%)
      6 (24) 11 (46) 0.109
      IQR = Interquartile Range LP = lumbar puncture.

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