Lumbar Punctures:
Logistics of the LP
Informed Consent - can use general informed consent form for procedures and fill in LP. Explain risks and benefits to the patient (see LP Clinic information)
Ensure coags/platelets are wnl. If patient is on an antithrombotic, please refer to the following guidelines: LP and Bleeding Risk
Do you need to check opening pressure? - If so, patient should be in lateral decubitus position. If not, can perform procedure while patient is seated.
Materials: LP Kit, extra lidocaine (ask nurse), a couple of chucks, an extra sterile sheet (if desired), iodine (chlorohexidine should not be used), sterile gloves, non-sterile gloves, specimen bags. An assistant (RN, medical student, co-resident, member of primary team if consult patient).
Perform “Time Out” with RN - fill time out form
Iliac crests correspond to L4-5 space. Aim here. Can also go 1 space above.
Procedure Note (MS IP MD LUMBAR PUNCTURE)
Please also remember to record your LPs in New Innovations so you can be credentialed for this procedure!
LP Studies
Routine Lumbar Puncture Order Set (easiest to obtain a written lab order form and fill it out by hand).
- Tube 1: Cell count, diff, gram stain
- Tube 2: Protein, glucose
- Tube 3: Cultures (bacterial, viral, fungal, AFB)
- Tube 4: Cell count, diff (again, to check clearing)
Other considerations
INFECTIOUS: VDRL/RPR, HIV, HSV PCR, EBV PCR, CMV PCR.
NEOPLASTIC: cytology, flow cytometry. For cytology, can empty a whole tube of CSF into a sterile cup (ask nurse) and then either (1) send immediately to cytology or (2) take to the lab to fix with 1:1 of 50% etoh.
AUTOIMMUNE/PARANEOPLASTIC: Consider the following tests in rapidly progressive dementias (most are send out tests, very expensive so consider utility, use paper lab order for ease): Anti-Hu (ANNA-1) (associated with SCLC), Anti-Ma2 (anti-Ta) (associated with testicular cancer), anti-CRMP-5, anti-NMDA receptor, anti-LGI1, anti-AMPA receptor, anti-GABA-B, anti-CASPR-2, anti-GlyR. Send most antibodies also from serum.
Consider RT-quic or 14-3-3 (CJD) in rapidly progressive dementia.
Multiple Sclerosis: IgG Synthesis Index Rate, Oligoclonal Bands. Also consider NMO serum IgG if clinically suggestive.
Post-LP
Delivering the tubes
Cytology: Atran 2 (must include "low concern for prion disease" on downtime form)
General labs & Flow Cytometry: Icahn 8
Ordering a Blood Patch for post-LP Headache
- Acute pain consult: 646 592-0145