Acute Headache in the Emergency Department: Is Lumbar Puncture Still Necessary to Rule Out Subarachnoid Hemorrhage?

The purpose of the Research to Practice column is to review current primary journal articles that directly affect the practice of the advanced practice nurse (APN) in the emergency department. This review examines the findings of Carpenter et al. (2016) from their article, "Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis Describing the Diagnostic Accuracy of History, Physical Exam, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds." The authors concluded that although no history or physical examination finding can be used to rule in or rule out spontaneous subarachnoid hemorrhage (SAH), the complaint of neck stiffness can increase the likelihood of SAH. In addition, the authors concluded that noncontrast head computed tomography (CT) is accurate in ruling out/in SAH when performed within 6 hr of symptom onset in adults with symptoms consistent with SAH and that the traditional gold standard of confirmatory lumbar puncture after a negative head CT scan is only helpful in patients with a very high pretest probability of SAH. By applying the evidence-based criteria presented in this study, the emergency department APN can confidently rule out SAH and reduce patient risks from unnecessary invasive and costly testing.

Expanding RN Scope of Practice to Include Lumbar Puncture.

: The competing demands of caring for high-acuity patients, reducing health care costs, and improving access to specialty care are complex challenges facing all health care providers. One approach-empowering nurses to expand their scope of practice-has been successfully employed for two decades by the nurse and physician leadership of a neurology department in an urban academic medical center. This article discusses the department's implementation of a quality improvement initiative to enhance access to neurology services in an ambulatory clinic by extending nursing practice to include lumbar puncture. Outcomes data from 2005 to 2016 demonstrate that through the department's comprehensive instructional program, RNs have competently and safely acquired new skills that have led to an expansion of their traditional roles, improved patient access to specialty care, and reduced costs.

Experience and nursing needs of school-age children undergoing lumbar puncture during the treatment of acute lymphoblastic leukaemia: a descriptive and qualitative study.

AIMS AND OBJECTIVES: To describe experiences and nursing needs of school-age Chinese children undergoing lumbar puncture for the treatment of acute lymphoblastic leukaemia. BACKGROUND: Lumbar puncture is an invasive procedure, causing psychological changes and physical discomfort in patients. In a previous study, it was proved that distraction intervention, such as music therapy, relieves pain and anxiety. There is limited evidence regarding the experience and needs of school-age children during lumbar puncture after being diagnosed with acute lymphoblastic leukaemia. To minimise their anxiety and pain during the procedure, it is important to collect information directly from these children. DESIGN: A descriptive qualitative research. METHODS: Twenty-one school-age children with acute lymphoblastic leukaemia participated in semi-structured interviews at a Children's Hospital in China. Data were collected by an experienced and trained interviewer. Qualitative content analysis was chosen to describe experiences of children undergoing lumbar puncture. RESULTS: While undergoing lumbar puncture for the treatment of acute lymphoblastic leukaemia, school-age Chinese children experienced complex psychological feelings (fear, tension, helplessness, sadness and anxiety). They also experienced physical discomfort. They had multipolar needs, such as information, communication, respect, self-actualisation, environment and equipment. CONCLUSIONS: This study identified important areas that must be closely monitored by healthcare staff, performing lumbar puncture on acute lymphoblastic leukaemia children. Thus, a successful and smooth procedure can be performed on these patients, and their quality of life can be improved. RELEVANCE TO CLINICAL PRACTICE: The experiences described in this study contribute to a better understanding of the needs of acute lymphoblastic leukaemia children undergoing lumbar puncture. They also provide valuable information to professional medical care staff that develops future nursing assessments.

[Post-dural puncture headache: risk factors, associated variables and interventions]. / La cefalea post-rachicentesi: fattori di rischio, variabili correlate ed interventi. Revisione della letteratura.

AIM: To identify nurses' doubts and questions (about lumbar puncture, related nursing interventions and post-dural puncture headache - PDPH) and to find answers in the available literature. METHODS: 26 nurses were asked to identify open questions and a literature review was conducted searching on Medline, Cochrane database of Systematic Reviews and Cinahl. RESULTS: Atraumatic needles, small gauge, cranial bevel oriented insertion and stylet reinsertion are variables that reduce the risk of PDPH. Bed rest has no efficacy in reducing this complication. On the contrary, it may increase the risk of PDPH. There are not enough evidences about the efficacy of additional fluid intake after the procedure. It's not clear if the risk of PDPH could be affected by the position during lumbar puncture and the volume of cerebrospinal fluid withdrawn. CONCLUSIONS: This literature review clarifies some aspects of lumbar puncture and PDPH: the use of traumatic or atraumatic needles, the bevel orientation and stylet reinsertion, bed rest. More research is needed to study the efficacy of other interventions, still uncertain (patient position during the procedure, volume of cerebrospinal fluid withdrawn, hydration and analgesic drugs' efficacy).

Evidence-Based Practice Recommendations to Prevent/Manage Post-Lumbar Puncture Headaches in Pediatric Patients Receiving Intrathecal Chemotherapy.

Post-lumbar puncture headaches (PLPHs) are a known complication of lumbar puncture procedures. Children undergoing treatment for cancer often undergo multiple lumbar punctures, placing them at increased risk for PLPHs. There are currently no guidelines for the prevention or management of PLPHs in children. A team was therefore assembled to conduct a systematic review of the evidence in relationship to PLPHs in the pediatric population. Clinical questions were developed and used to guide the literature review. Twenty-four articles were deemed appropriate for use and were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Based on the review of evidence, strong recommendations are made for the use of smaller needle sizes and for the use of pencil point needles during lumbar puncture procedures. Weak recommendations are made for needle orientation and positioning following the procedure as well as for interventions used to treat PLPHs once they occur. There is a need for additional, pediatric-specific studies to further examine the issue of PLPH prevention and treatment.

Post-lumbar puncture headache: a review of issues for nursing practice.

Headache is the most common complication after lumbar puncture. This narrative review explores the literature to determine strategies for preventing headache and provide evidence-based nursing care to adults with post-lumbar puncture headache. Multiple findings regarding prevention and relieving of post-lumbar puncture headache were identified and summarized under the headings "Needle Design and LP Technical Procedure," "Bed Rest and Early Mobilization," "Posture and Head Position," "Cerebral Vasoconstriction," "Hydration and Seal of the Puncture Site," and "Patient Characteristics." Despite the amount of articles, no widely accessible nursing practice guidelines were found. It has been shown that several treatments with insufficient or low levels of evidence supporting their efficacy are still being used (e.g., prolonged bed rest, special postures in bed, additional fluid intake, and caffeine intake). A clear recommendation regarding using atraumatic, small-sized needles. Further research is needed to support nursing with stronger evidence.

Lumbar puncture.

This article discusses the need for lumbar puncture, preparation of the patient and equipment necessary for this procedure. The rationale for the intervention is described with a focus on the nursing management before, during and after the procedure.

Pain management practices for lumbar punctures: are we consistent?

In most pediatric oncology centers across Canada, it is now standard practice for children to be sedated for lumbar punctures (LPs). Although the use of sedation for LPs is well established in the pediatric oncology population, its use in other hospital units is not well documented. A patient record audit was completed to understand the types of pain management strategies used for LPs performed throughout a pediatric hospital. Fifty-nine patients aged between 3 days and 17 years underwent a total of 67 LPs. Pain management strategies varied among the different patient service units. Oncology patients were consistently sedated for an LP, whereas patients in the emergency department were less likely to be given any type of sedation. Recommendations are aimed at providing consistent best practice pain management for LPs throughout the hospital.

Prevention and management of post-lumbar puncture headache in pediatric oncology patients.

Pediatric oncology patients are at risk for developing a headache after they undergo a lumbar puncture for diagnostic or therapeutic purposes. These headaches are likely due to leakage of cerebrospinal fluid at the puncture site. While usually mild and self-limited, some headaches may be persistent and severe, adding to the distress of these young patients. In the past 10 years, refinements in lumbar needle size and shape as well as procedural techniques have reduced the tissue trauma that predisposes patients to headache. A number of interventions, such as bed rest, hydration, caffeine administration, and epidural blood patching, have been suggested to prevent and relieve the headaches that follow lumbar punctures. This article outlines the pathophysiology and incidence of headaches related to lumbar punctures in the pediatric oncology setting and reviews the evidence from research trials to suggest which interventions clinicians should adopt into their practice to minimize this complication of lumbar punctures.

[The patients' care after lumbar puncture: hydration and bed rest?]. / Dopo la puntura lombare il paziente deve rimanere a letto ed essere idratato?

UNLABELLED: Headache after cervical or lumbar puncture has long been attributed to early mobilization; however, several trials and meta-analysis did not show any benefit from bed rest. AIM: The aim of the survey was to describe the patients' care after lumbar puncture. METHODS: A phone interview was administered to the head nurses of 50 neurological wards of Lumbardy and Veneto Region. RESULTS: All patients are kept at bed rest after the procedure from 3 to 24 hours. They are hydrated in 45 centres (i.v. or per os) with amounts of fluids ranging from 500 to 2500 ml. In 14 wards the patients fast until the afternoon, and are allowed only fluids. CONCLUSIONS: Although there is no evidence for the use of increased fluids or bed rest to prevent post dural puncture headache, these and other non evidence based practices continue to be used. Further research is warranted on strategies to implement an evidence based patients care.