A recent cohort study using the Danish nationwide medical registry demonstrates that the incidence of a spinal or epidural hematoma from lumbar punctures in patients with pre-existing thrombocytopenia (Platelets<150 K) or coagulopathy (INR>1.4 or aPTT>39 seconds) is not significantly higher…
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Class 1 evidence to inform decisions about the safety of lumbar punctures in patients with a coagulopathy are lacking. The only guidance we have regarding the safety of lumbar punctures is based on clinical guidance from organizations such as the…
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According to recent studies, atraumatic needles (ATN) reduce the rate of post-dural puncture headache (PDPH) when compared to traumatic needles (TN – or bevel-tip needles such as Quincke needles) (27% vs 60%).  Also, the mean duration of PDPH from ATN…
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Medical procedural education in the era of COVID19 is still best conducted via HANDS-ON simulation-based procedural training. Procedural skills can NOT be attained via remote education, but in-person training must be conducted safely. There are many topics and skills that can be successfully be taught online,…
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This blog will offer some expert recommendations to help guide the safety of hospital procedures at different platelet and coagulation profiles.  Unfortunately, there are no strong evidence-based guidelines for hospital procedures dedicated to the study of patients with decompensated cirrhosis.…
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The traditional landmark-guided needle lumbar puncture technique was first described by Heinrich Quincke in 1891[1]This technique utilizes the iliac crest and the posterior lumbar spinous processes to determine the optimal sites for spinal needle introduction in either the L3-4 or…
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This blog summarizes the guidelines by the European Society of Anesthesiology (ESA), the American Society of Regional Anesthesia (ASRA) and the Association of British Neurologists regarding the timing of antiplatelet and anticoagulation discontinuation before a lumbar puncture.  The following table…
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This blog summarizes the 2019 Society of Interventional Radiology (SIR) for Periprocedural Management of Image-guided Procedures with regards to thrombocytopenia, coagulopathies, antiplatelets and anticoagulation.  The SIR guidelines are summarized as follows: Anticoagulation with heparin, LMWH, fondaparinux, argatroban, warfarin, DOAC, clopidogrel, ticagrelor…
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Over the past several years, there has been a dramatic increase in the use of the new oral anticoagulants (Dabigatran, Rivaroxaban, and Apixaban).  The popularity of these medications stems not only from aggressive pharmaceutical monitoring to physicians and to the…
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Traditionally, it has been promulgated by anesthesiologists that you need a platelet count of 100,000 to safely perform neuraxial regional anesthesia (spinal and epidural anesthesia).  This practice pattern has continued even though Children’s Hospitals routinely perform intrathecal injections for prophylactic chemotherapy with…
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Diagnostic lumbar punctures aid in the diagnosis of infections and diseases of the central nervous system. Life-threatening events from lumbar punctures are rare, but post–lumbar (dural) puncture headaches (PDPH) occur in 1% to 36% of patients, depending on the needle…
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Lumbar puncture (LP), commonly performed in infants to rule out meningitis, is often not successful in the hands of inexperienced operators. Investigators conducted a study of 128 infants younger than 6 months. They compared traditional LP to LP preceded by…
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Traumatic lumbar puncture (LP) is fairly common and occurs when the needle causes bleeding into the subarachnoid space. Introduction of peripheral red blood cells (RBCs) in cerebrospinal fluid (CSF) increases CSF protein levels, thereby complicating diagnosis of bacterial meningitis. This…
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Pediatric lumbar punctures can have much higher success rates when proper positioning and technique are emphasized. The position should be the lateral decubitus position with hips flexed, but the neck does not need to be flexed. The spinal cord ends…
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Prior to the revised Swedish lumbar puncture guideline, a CT scan was often performed prior to lumbar puncture when acute bacterial meningitis was suspected. Taking the time to perform a CT scan of the head before lumbar puncture delays treatment…
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