lumbar punctures on infants?
- 0Jan 29, '06 by scrmblrI am a new ER nurse. I have always managed to avoid holding an infant for a spinal tap...Yesterday I ended up with a 23 day old who presented with a 100.8 fever. Doc orders the full workup:uhoh21: I manage to stick a feeding tube in his uncirc'd penis, swab his nose (twice) start an IV with lab draws and blood culture and try to comfort his (non english speaking) family. This was nothing compared to what the doc did. I knew the position to hold baby in. (I had at least SEEN that) but no matter what this doc did, he could not get spinal fluid. He poked this baby 5 times.
I have two questions...Did I do something wrong in my holding technique? I asked the doc a couple of times if he wanted me to change my positioning and he kept saying "no we are fine" But, I'm actually feeling guilty! As if it were my fault that this little guy got poked so many times. Second question...Why could this doc not get fluid? He kept saying "I know I'm in the right spot" It was the end of my shift and I didn't ask the doc any questions. For one, I didn't want to look stupid and for two, I was really upset about the full workup on this baby.
- 0Jan 29, '06 by suzi_hI have never done this or seen it done, however, when my son was 17 days old. He had a lumbar puncture, and then again 3 days later to confirm whether or not he had herpes, which he did not. But they hit blood vessels when they finally got fluid so, his RBC's were higher then normal. :angryfire I could have told them that. Anyways, not to be on a tangent. If it makes you feel any better, as a parent, I checked his back and he had multiple puncture spots. So, when they wanted to do it again, I was heartbroken and ******. His little scars lasted until he was quite a few months old, but he survived it. I am sure you did nothing wrong. That situation is, I would imagine, a very difficult one to perform and to deal with emotionally. I was told specifically not to be in the room. They told me it was pretty standard to do a lumbar pubcture on an infant that young with a fever as high as his was. I'm sure you did great, how exactly do you comfort anyone getting a spinal tap? :icon_hug:
- 0Jan 29, '06 by suzanne4What type of needle was the doc using to begin with? Butterflies actually work quite well in this size infant. You need their back to look like a cooked shrimp or a cat that is frightened and has their back up. Think knees to chin.
And it could easily have been the doc. Not all are that proficient on doing these.
Don't be so hard on yourself. There are also adult patients that they cannot obtain fluid on.
- 0Jan 29, '06 by ProfRN4although my experience was not on a baby, it was a situation where we just couldn't get the positioning right.
12 year old newly diagnosed w/ lymphoma. just happened to be recup-ing from a leg fracture, in a full leg cast (talk about a double whammy!!!). because of this tremendously heave and long cast, we couldn'y get him in the right position. wouldn't you know, that afternoon, ortho came around and cut the cast down to below the knee
so no, i wouldn't say it was your fault. the heme/onc attending tried 3 times, then the anesthesiologist tried. he couldn't get it either. and no one was blaming me. they actually felt bad for me, b/c i was stuck holding this leg up (as it hung off the table).
- 0Jan 29, '06 by canoeheadWe have one doc in our ER that does an LP on every other shift for one kid or another. The last time I just looked at her when she said to set up for one, she said "Well I don't ENJOY doing them!" Hey babe- you said it, not me.
Might I say as well, she has not yet actually gotten spinal fluid. Considering we ship anyone that is sick enough to need an LP maybe we could just send them to someone who knows how to do it. I know, I know, gotta start the antibiotics, so gotta do the tap first. DAMMIT I'm tired of going into kids rooms knowing we're going to torture them for no good reason.
- 0Jan 29, '06 by PedsER-RNseeing as the baby was stuck 5 times, i don't think it had to do with your method of holding. when we do lp's on infants, we usually hold them side-lying with their knees up to their chin. there is one doc who likes them to be sitting, but it's really hard trying to keep them aligned, still, and hold their head steady all at once. when we do a tap there's always two nurses in there, one to hold the baby and the other keeps the arms from waving on the sterile field.
anyway, don't be so hard on yourself. it does take a little practice to get your holding technique down where you feel comfortable with it, but don't always blame yourself if the doc misses (especially with 5 sticks). when i hold i always ask the doc before he pokes, "is this position good for you?". if not, the baby is repositioned, and if it is good, then there's no blaming the holder for a miss.
- 0Jan 29, '06 by prmenrsJust a hunch, but I think he couldn't get what wasn't there. If the baby was dehydrated, you frequently can't get CSF. Need to hydrate them, then try. You don't always have to do a spinal tap as part of the initial workup. You can wait @ least until the CBC differential is back. Meanwhile, hydrate!
Holding: Put a piece of tape @ the top of his diaper positioned just barely covering the gluteal fold. (Keeps him from contaminating things.) Take a hold of his shoulders, including the back of his head, w/your thumb on the front of his shoulder, and his bottom (think pelvis). Arch him forward firmly--you will not break him, honest. His head should be tucked down on his chest and his hips flexed against his tummy. He should be able to breathe. As long as he doesn't have resp distress, don't worry if it sounds like he can't cry all that well. His body will have a tendency to rotate forward, use your thumb against his shoulder and rotate your other hand to make it so his body is @ 90 degrees to the surface. ASK the doc if he's rotated, you won't be able to tell.
When he feels the needle, he will try to arch away, so be ready. You have already put him closer to the edge where the doc is, you are on the other side of the bed--lean w/your elbows on the surface--takes a little strain off you. When you can do this and still keep his pacifier in this mouth, consider yourself a pro.
I don't like using butterflys for this--it can be dangerous. Our attendings outlawed them. And always have an extra spinal needle or 2 in your pocket for good luck. And as soon as it's over and the bandaid is on, pick the baby up and comfort him. Also wash any leftover Betadine off.
Lesson 2 is on how to hold the baby sitting up. Let me know when you want it!
- 0Jan 30, '06 by ClaireMaclI've worked in a UK ED for years and have treated many kids with suspected meningitis etc but have never ever been asked to assist in an LP. I think I'd freak! It's traumatic enough for that baby getting an IV line, can't imagine an LP (though I know its sometimes necessary)!
Can I just say how great you all are that have assisted in this and the OP that I'd doubt it was anything they done at all!
- 0Jan 31, '06 by scrmblr:redpinkhe Thank you all for your comforting words
I was just thinking back to when I've seen other nurses go into a room with the dreaded "tray" and come back minutes later with the clear vials of fluid. So, it was pretty hard to not have any clear vials for lab!
I am feeling better after reading that sometimes it just isn't "textbook"