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					PERFORMING A LUMBAR PUNCTURE                                                    P-37

  Lumbar puncture is used to confirm the diagnosis when the baby has signs
  suggestive of meningitis. Do not perform a lumbar puncture if the baby has
  spina bifida/meningomyelocoele.

  •   clean examination gloves
  •   high-level disinfected or sterile gloves
  •   sterile drapes
  •   swabs or cotton-wool balls soaked in antiseptic solution (Table C-10,
      page C-41)
  •   spinal needle or intravenous needle (22- to 24-gauge)
  •   appropriate collection tubes
  •   dry cotton-wool ball
  •   adhesive bandage

  •   Be prepared to resuscitate the baby using a bag and mask (page P-1), if
  •   Gather necessary supplies.
  •   Place the baby under a radiant warmer (page C-5), if possible, and
      undress the baby only when ready to perform the procedure.
  •   Follow principles of infection prevention (page C-37) and aseptic
      technique (page C-40).
  •   Position the baby:
      -    Have an assistant hold the baby in a sitting position:
           -   Position the baby so that the baby’s legs are straight and the
               back is arched (Fig. P-15, page P-38);
           -   Ensure that the baby’s neck is partially extended and not flexed
               towards the chest, which could obstruct the baby’s airway.
P-38                                                        Performing a lumbar puncture

FIGURE P-15     Sitting position for lumbar puncture

       -   Alternatively, place the baby on her/his side facing the assistant
           (most right-handed health care providers find it easiest if the baby is
           on her/his left side; Fig. P-16):
           -   Position the baby so that the baby’s back is closest to the side of
               the table from which the lumbar puncture will be performed;
           -   Have the assistant place one hand behind the baby’s head and
               neck, and place the other hand behind the baby’s thighs to hold
               the spine in a flexed position;
           -   Ensure that the baby’s neck is partially extended and not flexed
               towards the chest, which could obstruct the baby’s airway.
FIGURE P-16     Lying position for lumbar puncture
Performing a lumbar puncture                                                       P-39

     •     Wash hands (page C-38), and put on clean examination gloves.
     •     Prepare the skin over the area of the lumbar spine and then the remainder
           of the back by washing in an outward spiral motion with a swab or
           cotton-wool ball soaked in antiseptic solution. Repeat two more times,
           using a new swab or cotton-wool ball each time, and allow to dry.
     •     Identify the site of the puncture between the third and fourth lumbar
           processes (i.e. on a line joining the iliac crests; Fig. P-17).
FIGURE P-17             Site of lumbar puncture

     •     Remove examination gloves and put on high-level disinfected or sterile
     •     Place sterile drapes over the baby’s body so that only the puncture site is
     •     Insert the needle in the midline of the vertebrae, angled towards the
           baby’s umbilicus.
     •     Slowly advance the needle to a depth of about 1 cm (or less if the baby is
           small [less than 2.5 kg at birth or born before 37 weeks gestation]). A
           slight “pop” may be felt as the needle enters the subarachnoid space.
     •     If using a spinal needle, remove the stylet.
     •     If bone is encountered, the needle cannot be redirected. Pull the needle
           back to just beneath the skin and reinsert the needle, directing it slightly
           upward while aiming for the baby’s umbilicus.
P-40                                                           Performing a lumbar puncture

       •   Collect the cerebrospinal fluid (CSF):
           -   Collect about 0.5 to 1 ml (about 6 to 10 drops) of CSF in each
               collection tube;
           -   If CSF does not come out, rotate the needle slightly;
           -   If CSF still does not come out, remove the needle and reinsert it
               between the fourth and fifth lumbar processes;
           -   If blood is seen in the CSF, the needle probably went through the
               spinal canal and caused bleeding. If the CSF does not clear, collect
               enough CSF for culture and sensitivity only.
       •   After the CSF is collected, remove the needle.
       •   Have an assistant apply gentle pressure to the puncture site with a cotton-
           wool ball until bleeding or leakage of fluid stops.
       •   Apply an adhesive bandage to the site.