Lumbar Puncture - Acceptable Practice

[Lush80]

Hello Nurses,

My question today is around lumbar punctures on adults.

A Nurse Practitioner that I've been interacting with (in hematology) recently attempted 6-8 (6 according to NP, 8 according to patient and observing family member) consecutive, unsuccessful LPs on a 65 year old lymphoma patient. She never gave the patient a break, never verbally checked in with him to see if she could continue, and never attempted to get assistance from anyone else.

Is this acceptable practice? I know with venipunctures after 2-3 attempts, often another nurse or a technician is asked to step in to try. I can't understand how 6-8 times is acceptable for an LP which carries more risk than an VP?

FYI in the end, they took him down to radiology and the radiologist attempted another 7 times. He suspects there's blood in there which makes it difficult to aspirate the CSF. All of this in a span of a few hours.

The floor manager and staff are protecting her, saying 6 attempts are normal, but it's not sitting right with me. Thoughts?

[Rose_Queen, BSN, MSN, RN]

In what context are you asking this question? If you are the patient or a family member of a patient, this is not the place to be asking these questions. Instead, these questions should be asked of the facility where this occurred. Even if you were a member of the care team, this would be based on facility policy, and should be asked of someone with knowledge in the facility.

[brownbook]

In the ideal world it is kind of, sort of, vaguely "unacceptable" but only in a common sense way. Common sense says the practitioner is going to get frustrated, tired, etc., and the patient should be physically and emotionally assessed when awake for such a procedure.

Policies and standards are specifically vague (that sounds like an oxymoron?). You won't find any policy or standard that says....only 2 IV attempts, or only 4 lumbar puncture attempts, or gives specifics on most situations.

If I were physically in the room during this, as the patient's nurse, or as a family member, I would have said to the patient..."are you doing okay, do you need a break?"

Hopefully it was a good learning lesson for all involved. I doubt the practitioner feels very good about how it turned out.

[KatieMI, BSN, MSN, RN]

I bet there is no policy explicitly saying "only X attempts before next Y step". Things like this are usually going, for better or worse, under generic umbrella of "getting it done or proving it impossible", with the latter statement implying many attempts before calling it quit.

I'd seen 10+ attempts LP (c-section, known difficult airway) which was followed with very many attempts to intubate, 3+ hours Quinton placement with God only knows how many attempts and every single upper body big vessel used, and other things along the line more times than I can count. The goal is to get it done, while avoiding complications whenever possible. And even when complications happen, there is that informed consent sheet. So, while the NP kinda possibly entered some sort of gray zone (at least from that IR man point of view), legally nothing wrong was done. That particular patient had "impossible" subarachnoid space at a particular level, a common thing, BTW. Proven beyond doubts, hopefully will be made known for future providers. Otherwise, yes, normal, although it would be nice for someone else to hold hand and tell something nice... and get the family outta the scene.