Adult Lumbar Puncture Page 1 of 3 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care.

Note: This algorithm is used by Acute Care Procedures Team, also known as Mobile Procedure Team (MPT) LP parameters: ● Anatomical site is limited to L3-4 and L4-5 Provider identifies ● For significantly obese patients with obscuring landmarks, patient need for lumbar consider using ultrasound4 at the bedside Post procedure: puncture (LP) and pages Pre-LP requirements: ○ Use to mark site and measure depth on spinal Notify primary team MPT proceduralist via ● Discuss with primary team and schedule image, if available, to determine needle length needed to and MPT for on-call calendar procedure to be done under conscious attempt procedure sedation if patient has anxiety or is findings of ● Obtain CSF with no more than a total of 3 needle stick unable to assume position for procedure positional , attempts Provider and on-call ● CT or MRI head obtained within 30 days site leak, , ● Post-procedure, the patient must remain supine for at least MPT proceduralist to of procedure request or changes in 30 minutes and/or based on the amount of CSF removed discuss: ○ If new onset of neurologic changes at neurological status Yes ● If failed attempt to obtain fluid, document reason in patient ● Reason for procedure time of assessment, must obtain current post LP note; consider follow up reassessment at bedside or in ● If the patient is head imaging to rule out worsening outpatient clinic hemodynamically intracranial pathology 1 ● Log specimen collected in specimen log and document in stable ● Lab parameters: LP procedure note the specimen pick up request/staff name ● Anticoagulation ○ INR < 1.5 and requirements medication history2 met? ○ > 50 K/microliter For MPT to perform LP, the following must be ● Completion of LP ● For high volume taps due to multiple obtained from Neuro-oncology and/or order set [if duplicate Findings of edema, studies: staff: order for procedure ○ Discuss the appropriate lab(s) needed intracranial shift, metastatic No ● Assessment, documented clearance, and was also placed to a lesion, mass, bleed or with the ordering attending (procedure MD/DO to chaperone the procedure (if needed) different service (i.e., ○ Determine the minimal volume of hemorrhage on CT/MRI head escalation ● Instructions on the minimal volume of CSF DI), contact other 3 (CSF) needed required ) needed proceduralist service History of lumbosacral after procedure Threshold surgery with instrumentation, Contact diagnostic imaging to perform LP completion] Minimum Threshold to post-surgical scars, wounds, under Procedure infuse platelets INR or drain over procedure site threshold during procedure ● Must correct coagulopathy prior to LP Lumbar Coagulopathy (INR > 1.5 and ● Strongly consider LP to be done 50 K/microliter 40-50 K/microliter 1.5 platelets < 50 K/microliter) Puncture under fluoroscopy, if high risk for bleeding 1 Heart rate > 65 bpm, SBP > 100 mmHg and oxygen saturations > 90% (unless decreased oxygen saturation due to ascites) 2 The Mobile Procedure Team (MPT) or the Brain and Spine Clinic will determine anticoagulation hold times, if applicable. The Peri-Procedure Management of Anticoagulants algorithm may be utilized as well. 3 Procedure may not be completed by MPT and may require an alternate specialized provider to perform 4 For pre-assessment and procedure, only use high level disinfected ultrasound probe that is covered with a sterile cover and sterile individual gel packs Department of Clinical Effectiveness V3 Approved by the Executive Committee of the Medical Staff on 08/18/2020 Adult Lumbar Puncture Page 2 of 3 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care.

SUGGESTED READINGS

Abel, S., Brace, R., Mckinney, M., Friedman, I., Smith, D., Westesson, L., . . . Lee, S. (2014). Effect of patient positioning on cerebrospinal fluid opening pressure. Journal of Neuro- Ophthalmology, 34(3), 218–222. https://doi.org/10.1097/WNO.0000000000000074

Arevalo-Rodriguez, I., Ciapponi, A., Figuls, M., Munoz, L., & Cosp, X. (2016). Posture and fluids for preventing post-dural puncture headache. Cochrane Database Of Systematic Reviews, 3(3), CD009199. https://doi.org/10.1002/14651858.CD009199.pub3

Chakraverty, R., Pynsent, P., & Isaacs, K. (2007). Which spinal levels are identified by palpation of the iliac crests and the posterior superior iliac spines? Journal of Anatomy, 210(2), 232–236. https://doi.org/10.1111/j.1469-7580.2006.00686.x

Conroy, P., Luyet, C., McCartney, C., & McHardy, P. (2013). Real-time ultrasound-guided : A prospective observational study of a new approach. Anesthesiology Research and Practice, 2013, 7. https://doi.org/10.1155/2013/525818

Margarido, C., Mikhael, R., Arzola, C., Balki, M., & Carvalho, J. (2011). The intercristal line determined by palpation is not a reliable anatomical landmark for neuraxial anesthesia. Canadian Journal of Anesthesia/Journal Canadien D’anesthésie, 58(3), 262–266. https://doi.org/10.1007/s12630-010-9432-z

Peterson, M., Pisupati, D., Heyming, T., Abele, J., & Lewis, R. (2014). Ultrasound for routine lumbar puncture. Academic Emergency Medicine, 21(2), 130–136. https://doi.org/10.1111/acem.12305

Rajagopal, V., & Lumsden, D. (2013). BET 4: Does leg position alter cerebrospinal fluid opening pressure during lumbar puncture? Emergency Medicine Journal, 30(9), 771–773. https://doi.org/10.1136/emermed-2013-202981.4

Shaikh, F., Brzezinski, J., Alexander, S., Arzola, C., Carvalho, J., Beyene, J., & Sung, L. (2013). Ultrasound imaging for lumbar punctures and epidural catheterisations: Systematic review and meta-analysis. British Medical Journal, 346, f1720. https://doi.org/10.1136/bmj.f1720

Thoennissen, J., Herkner, H., Lang, W., Domanovits, H., Laggner, A., & Mullner, M. (2001). Does bed rest after cervical or lumbar puncture prevent headache? A systematic review and meta- analysis. Canadian Medical Association Journal, 165(10), 1311–1316. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC81623/pdf/20011113s00018p1311.pdf

Williams, J., Lye, D., & Umapathi, T. (2008). Diagnostic lumbar puncture: Minimizing complications. Journal, 38, 587-591. https://doi.org/10.1111/j.1445-5994.2008.01631.x

Department of Clinical Effectiveness V3 Approved by the Executive Committee of the Medical Staff on 08/18/2020 Adult Lumbar Puncture Page 3 of 3 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care.

DEVELOPMENT CREDITS

This practice consensus statement is based on majority opinion of the Acute Care Services Department at the University of Texas MD Anderson Center for the patient population. These experts included:

Ivy Cocuzzi, PA-C (Acute Care Services)Ŧ Wendy Garcia, BS♦ Susanna Girocco, PA-C (Acute Care Services) Tam Huynh, MD (Thoracic & Cardiovascular Surgery) Amy Pai, PharmD, BCPS♦ Kimberly Tripp, MBA, BSN, RN (Acute Care Services Administration)

Ŧ Core Development Team ♦ Clinical Effectiveness Development Team

Department of Clinical Effectiveness V3 Approved by the Executive Committee of the Medical Staff on 08/18/2020