Lumbar Puncture Procedure Note

Before the procedure:

  1. Obtain consent.  Inform regarding complications (esp. headache 22%, back pain 25%, bleeding, infection, cerebral herniation)
  2. Note contraindications:  raised ICP, thrombocytopenia or other bleeding diathesis, anticoagulation, suspected spinal epidural abscess

Procedure Note

Procedure:  Lumbar puncture, bedside
Exam Date:  <today’s date>
Fellow: <Dr. _____>, Fellow in Neurocritical Care
Supervising Physician:  <Dr. _____>

Clinical Indication:
[Urgent] suspected CNS infection (not brain abscess or parameningeal process) – Patient presents with fever, AMS, headache, meningeal signs
[Urgent] suspected subarachnoid hemorrhage in patient with negative CT scan
[Nonurgent] Idiopathic intracranial HTN (pseudotumor cerebri)
[Nonurgent] Carcinomatous meningitis
[Nonurgent] tuberculous meningitis
[Nonurgent] normal pressure HCP
[Nonurgent] CNS syphilis
[Nonurgent]  CNS vasculitis
[Others] MS, GBS, paraneoplastic
[therapeutic or diagnostic] spinal anesthesia, intrathecal chemo, intrathecal Abx, myelography or cisternography

CONSENT:  Patient is alert and oriented to person, place and time and he/she appeared to understand the indications, risks and benefits of the procedure.  Patient is able to give both verbal and written consent.

PROCEDURE:  The patient was placed in a [right/left] sidelying osition.  The skin overlying the L3-L4 interveertebral space was identified using the iliac crests as landmarks.  This area was prepped and draped in sterile fashion.  Skin and soft tissue anesthesia was achieved with 1% lidocaine, 5 mL.  A [20/22]-gauge 3.5 inch spinal needle was introduced and advanced in a single puncture into the subarachnoid space.  The stylet was removed with appropriate return of [clear] fluid.  40 mL of clear CSF was obtained and placed in 4 vials.  These vials were identified with the patient’s name and medical record number.  Needle was removed after adequate fluid collected.  Blood loss was minimal.

The tubes were sent for the following tests:

  • Tube 1: Cell Count
  • Tube 2: Gram Stain, CSF Culture, Glucose, Protein, Other …
  • Tube 3: Pt ID placed and held if further CSF studies indicated
  • Tube 4: Cell Count

Opening Pressure:  obtained while patient in lateral decubitus position is ____ cm H2O

Fluid appearance:  clear / bloody

The patient tolerated the procedure well, without any complaints.  The procedure was completed without any complications.

Simplified LP Procedure Note

Procedure – Lumbar Puncture
Indication – [insert here]
Anesthesia – local 1% lidocaine w/ epi

Informed consent was obtained from the patient.  The area was prepped and draped in the usual sterile fashion. Using landmarks, a 22 guage spinal needle was inserted in the L4-L5 innerspace. The stylet was removed and the opening pressure was measured at 18 cm of water. 4cc of clear fluid was collected and sent for routine studies. CSF was also sent for [other studies].
The patient tolerated the procedure well. There was no blood loss or hematoma.

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