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I gave this at a recent practical session for RNs, NPs, and PAs associated with a neurosurgical conference
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Joe Hlavin PA-C
Lumbar drainsLumbar puncture
Not a big difference between the two▪ Same technique▪ Both take off CSF
The differences are the reasons▪ And results
The use of an implanted soft tube placed in the lumbar thecal sac for the purpose of continuously or intermittently draining CSF
Generally requires discussion and consent with the patient
Performed under sterile conditions but can be done at the bedside
Implications Adjunct to the treatment of post op or
traumatic CSF leaks secondary to dural opening or injury
Rhinorrhea – traumatic and surgically induced
Alternative CSF pathway if VPS is removed for infection
Reduce ICP during craniotomy Decrease ICP in TBI
Procedure Patient position▪ Lateral decubitus or sitting bent forward over tray▪ Practitioner preference and patient status
depends I use a lumbar puncture tray – has
everything I need Just need gloves and the ELD kit de jour EXPLAIN to patient what you are doing if MS
permits
Practitioner’s choice I prefer the lateral decubitus I palpate the iliac crest with index and
middle finger then straight across I place my thumb which will be L4-5
Pitfalls Older patients with stenosis – go higher Angle of attack - start midline, then go to
the right or left
See where L4-5 is relativeto the iliac crest
Must be intradural to get CSF
NOTE – Keep bevel of needle CEPHALAD
WHY?
Once I have CSF return I will Feed in the catheter NOTE – make sure that the bevel is
UP/CEPHELAD so the the catheter goes UP If you meet resistance, don’t worry – make
SMALL adjustments in depth and resist the urge to aim needle up – this will only bring the bevel more dorsal. Angle down to open the bevel to the canal
Run the catheter in until you reach 4 dots
Secure the drain after needle is removed NOTE – do not lose sight of the catheter
– they are sneaky and will start to come out
I use benzoin, or sticky stuff de jour, around the catheter entrance then an opsite dressing
2 -3 inch tape to run it up the back to the shoulder
Attach the Becker drain – leave closed until everyone is done “messing” with the patient
Then set the drain to 10 ml/hour or 80cc/8-hour shift NOTE – I like to use the one time drain
per shift to avoid the ICU staff from opening and forgetting.
Remember that this is a closed sterile system but would recommend Atbx while drain is in.
Actually placing the lumbar drain is only part of the care of the patient What is the information we can get?▪ CSF for culture▪ Pressure readings▪ A dry wound
How long do we leave it in?▪ What result(s) are we looking for?▪ When is the right time to remove?
Reviewing initial slides Refer to the approach and needle
placement▪ Approx. L4-5▪ Intradural▪ Look for CSF return
Diagnostic R/O SAH with neg CT▪ Xanthochromia
Meningitis – HA/Fever ▪ Protein, WBC, glucose
NPH – draining improves pt Psuedotumor Cerebri - pressure MS – IgG, Oligoclonal bands
Therapeutic (RARE) Periodic treatment of psuedotumor▪ Periodic visual impairment
Careful – CT first in impaired pt and know the coags
Thank you