**Emergency Pericardiocentesis in Children**

**Emergency Pericardiocentesis in Children**

DOI: 10.5772/intechopen.70700

#### Cecilia Lazea Additional information is available at the end of the chapter

Cecilia Lazea

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70700

#### **Abstract**

Cardiac tamponade is a life-threatening condition characterized by compression of the heart due to pericardial accumulation of different types of fluid and requires prompt diagnosis and immediate therapeutic intervention. Echocardiography is the most useful imaging technique to diagnose the cardiac tamponade and to evaluate the size, location, and hemodynamic impact of the pericardial effusion. Emergency pericardiocentesis is the procedure used for the aspiration of the fluid from the pericardial space in patients with significant pericardial effusion which determines hemodynamic compromise (cardiac tamponade). Emergency pericardiocentesis in children is performed under local anesthesia and is echocardiographic-guided. The first step of echocardiographic-guided pericardiocentesis is to assess the dimension and distribution of the pericardial fluid and the optimal trajectory of the needle in order to efficiently evacuate the pericardial fluid. The transducer is situated 3–5 cm from the parasternal border and the trajectory of the needle is established by the angle of the transducer. The needle is positioned between the xiphoid process and the left costal cartilages and is advanced, while a continuous aspiration is performed. It is important to avoid the neighboring vital organs (heart, liver, lung, internal mammary artery, and the intercostal vascular bundle). Complications which can occur are as follows: dysrhythmias, puncture of coronary artery or mammary artery, hemothorax, pneumothorax, pneumopericardium, and hepatic injury.

**Keywords:** pericardiocentesis, emergency, children, cardiac tamponade

#### **1. Introduction**

Pericardiocentesis is indicated in hemodynamic unstable children with cardiac tamponade. Echocardiography is a useful imaging tool for liquid effusion visualization and for needle trajectory, reducing the risk of complications.

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

## **2. Cardiac tamponade**

#### **2.1. Definition**

Cardiac tamponade is a life-threatening condition characterized by compression of the heart due to pericardial accumulation of different types of fluid in the pericardial space, which determines restriction from normal filling of the cardiac chambers. Other causes that can determine cardiac tamponade are as follows: inflammation, trauma, aortic dissection, and rupture of the heart [1]. This condition requires prompt diagnosis and immediate therapeutic intervention.

consequences, depending on the rate of liquid accumulation in the pericardial sac. Slow accumulation of the fluid cannot produce clinical symptoms, even when a large quantity of fluid is present, while a rapid accumulation of pericardial fluid will determine a sudden increase of the intrapericardial pressure with severe clinical and hemodynamic consequences. Cardiac tamponade can appear in case of sudden increase of the intrapericardial fluid volume or in case of progressive increase of the pericardial fluid beyond the point of possible pericardial distension. In cardiac tamponade, the diastolic filling is severely reduced because of the increased intrapericardial pressure and conversely, the cardiac output will be reduced. During inspiration, the right ventricle is expanded because of the increased inflow, while during expiration, the left ventricle is expanded and causes the diastolic collapse of the right ventricle and right atrium [2, 3, 9, 10].

Emergency Pericardiocentesis in Children http://dx.doi.org/10.5772/intechopen.70700 77

During the initial stages, ejection fraction and heart rate are increased and consecutively, the cardiac output is preserved. Lately, the compensatory mechanisms are not effective and systemic vascular resistance are increased, in order to maintain systemic blood pressure, with systemic perfusion compromising and finally with decreased myocardial function, reduced cardiac output, and blood pressure. Clinically, the Beck's triad expresses these pathophysiological changes described above and consists of distant heart sounds, hypotension, and jugular venous distension because of elevated central venous pressure. Other clinical signs are diminished peripheral pulses, pulsus paradoxus (a decrease in systolic blood pressure of >10 mmHg during inspiration), hepatomegaly, and Kussmaul's sign (increased jugular venous pressure during inspiration). In late phases, cyanosis and decreased level of con-

Cardiac tamponade is diagnosed clinically and on echocardiography, but there are other use-

Chest radiography can reveal an increased cardiac silhouette ("water-bottle" shape) or a nor-

Decreased electrocardiographic voltage and electric alternans (alternating P wave, QRS complex, and T wave voltages because of the swinging motion of the heart) are characteristics of

Echocardiography is the most useful imaging technique to diagnose the cardiac tamponade and to evaluate the size, location, and hemodynamic impact of the pericardial

**2.4. Clinical presentation**

sciousness can be present [1–3, 9–11].

ful diagnostic investigations.

mal-appearing cardiac silhouette.

*2.5.1. Chest radiography*

*2.5.2. Electrocardiography*

cardiac tamponade.

*2.5.3. Echocardiography*

**2.5. Diagnosis**

#### **2.2. Etiology**

Cardiac tamponade can appear in children as a result of the following conditions (**Table 1**).

Accumulation of transudative fluid into pericardial space can occur from obstruction of fluid drainage, while exudative fluid accumulation appears secondary to inflammation, infections, autoimmune, and malignant diseases.

#### **2.3. Physiopathology**

Pericardium envelops the heart and consists of two layers (the visceral pericardium and the parietal pericardium), which are separated by a virtual space containing a small amount of fluid (about 20 mL), serving as lubricant. Normally, pericardium has little effect on cardiovascular function as the following: preservation of the interaction between the left and right ventricle during the systole and diastole, limitation of the intrathoracic cardiac movement and acute cardiac dilatation, minimization of the friction between the heart and neighboring structures by the presence of a small amount of fluid in the pericardial space, and anatomic barrier for pulmonary infections by lymphatic structure [1–3]**.**

Abnormal pericardial fluid production will determine an increased intrapericardial pressure, when the normal capacitance volume of the pericardium is exceeded, with hemodynamic


**Table 1.** Causes of cardiac tamponade [1–8].

consequences, depending on the rate of liquid accumulation in the pericardial sac. Slow accumulation of the fluid cannot produce clinical symptoms, even when a large quantity of fluid is present, while a rapid accumulation of pericardial fluid will determine a sudden increase of the intrapericardial pressure with severe clinical and hemodynamic consequences. Cardiac tamponade can appear in case of sudden increase of the intrapericardial fluid volume or in case of progressive increase of the pericardial fluid beyond the point of possible pericardial distension. In cardiac tamponade, the diastolic filling is severely reduced because of the increased intrapericardial pressure and conversely, the cardiac output will be reduced. During inspiration, the right ventricle is expanded because of the increased inflow, while during expiration, the left ventricle is expanded and causes the diastolic collapse of the right ventricle and right atrium [2, 3, 9, 10].

#### **2.4. Clinical presentation**

**2. Cardiac tamponade**

autoimmune, and malignant diseases.

barrier for pulmonary infections by lymphatic structure [1–3]**.**

**Common causes Uncommon causes**

Infectious pericardial effusion (viral, pyogenic, tuberculous)

Neoplasia (metastases, leukemia, lymphoma) Postcardiac surgery (postpericardiotomy syndrome) Collagen vascular diseases (systemic lupus erythematosus)

**Table 1.** Causes of cardiac tamponade [1–8].

Trauma (hemopericardum)

Cardiac tamponade is a life-threatening condition characterized by compression of the heart due to pericardial accumulation of different types of fluid in the pericardial space, which determines restriction from normal filling of the cardiac chambers. Other causes that can determine cardiac tamponade are as follows: inflammation, trauma, aortic dissection, and rupture of the heart [1]. This condition requires prompt diagnosis and immediate therapeutic

Cardiac tamponade can appear in children as a result of the following conditions (**Table 1**).

Accumulation of transudative fluid into pericardial space can occur from obstruction of fluid drainage, while exudative fluid accumulation appears secondary to inflammation, infections,

Pericardium envelops the heart and consists of two layers (the visceral pericardium and the parietal pericardium), which are separated by a virtual space containing a small amount of fluid (about 20 mL), serving as lubricant. Normally, pericardium has little effect on cardiovascular function as the following: preservation of the interaction between the left and right ventricle during the systole and diastole, limitation of the intrathoracic cardiac movement and acute cardiac dilatation, minimization of the friction between the heart and neighboring structures by the presence of a small amount of fluid in the pericardial space, and anatomic

Abnormal pericardial fluid production will determine an increased intrapericardial pressure, when the normal capacitance volume of the pericardium is exceeded, with hemodynamic

Postcardiac percutaneous procedures

Transvenous pacemaker lead implantation

Radiofrequency ablation

Radiation therapy Chemotherapy Myocardial infarction Aortic dissection Hypothyroidism Kawasaki disease Juvenile idiopathic arthritis

Rheumatic fever

**2.1. Definition**

76 Bedside Procedures

intervention.

**2.2. Etiology**

**2.3. Physiopathology**

Uremia

During the initial stages, ejection fraction and heart rate are increased and consecutively, the cardiac output is preserved. Lately, the compensatory mechanisms are not effective and systemic vascular resistance are increased, in order to maintain systemic blood pressure, with systemic perfusion compromising and finally with decreased myocardial function, reduced cardiac output, and blood pressure. Clinically, the Beck's triad expresses these pathophysiological changes described above and consists of distant heart sounds, hypotension, and jugular venous distension because of elevated central venous pressure. Other clinical signs are diminished peripheral pulses, pulsus paradoxus (a decrease in systolic blood pressure of >10 mmHg during inspiration), hepatomegaly, and Kussmaul's sign (increased jugular venous pressure during inspiration). In late phases, cyanosis and decreased level of consciousness can be present [1–3, 9–11].

#### **2.5. Diagnosis**

Cardiac tamponade is diagnosed clinically and on echocardiography, but there are other useful diagnostic investigations.

#### *2.5.1. Chest radiography*

Chest radiography can reveal an increased cardiac silhouette ("water-bottle" shape) or a normal-appearing cardiac silhouette.

#### *2.5.2. Electrocardiography*

Decreased electrocardiographic voltage and electric alternans (alternating P wave, QRS complex, and T wave voltages because of the swinging motion of the heart) are characteristics of cardiac tamponade.

#### *2.5.3. Echocardiography*

Echocardiography is the most useful imaging technique to diagnose the cardiac tamponade and to evaluate the size, location, and hemodynamic impact of the pericardial effusion. Emergency echocardiographic assessment of tamponade includes two stages: first stage demonstrates the presence of pericardial fluid collection and the second stage assesses the hemodynamic effects of previously detected collection [12]. The first sign of hemodynamic impairment in tamponade is collapse of the right ventricle free wall in early- to mid-diastole because of the increased intrapericardial pressure more than ventricular transmural distending pressure, and is very specific (**Figure 1**). Right atrial collapse appears in late diastole and has high specificity. The absence of the right chamber collapse is present in cases of elevated diastolic pressure in the right chambers, such as pulmonary hypertension, positive pressure ventilation, or severe left ventricle failure [9]. When tamponade progresses, left atrial late-diastolic collapse and left ventricle early-diastolic collapse can appear. Dilatation of inferior vena cava without normal inspiratory variation (less than 50% decrease in diameter during inspiration), known as inferior vena cava plethora, has also high sensitivity for cardiac tamponade. Other signs are swinging heart, respiratory variation in ventricular chamber size, pseudosystolic anterior motion of the mitral valve, fluttering of the ventricular septum, and dilated hepatic veins [1–4, 10, 12–15]. The absence of the heart chamber collapse is considered as a negative predictive sign for cardiac tamponade [9].

filling pressure, oliguria, decrease of chest drainage, pulsus paradoxus, cardiac arrest, and

Emergency Pericardiocentesis in Children http://dx.doi.org/10.5772/intechopen.70700 79

Doppler echocardiography is another useful tool for diagnosis of tamponade, showing large variations with respiration (more than 30%) in the amplitude of inflow and outflow signals,

• Mitral valve: exaggerated decrease in mitral inflow (E wave velocity) during inspiration

• Tricuspid valve: exaggerated increase in tricuspid inflow (E wave velocity) during

• Peak velocities in left and right outflow tracts have a large difference with respiratory cycle. During inspiration, there is a drop of peak velocity in the aorta, while in the right ventricu-

• Hepatic veins: increased S wave velocity during inspiration; decreased or absence of D

Although there are many echocardiographic signs, none of these findings are entirely diagnostic of cardiac tamponade, so the diagnosis is based on both clinical and ultrasound assessment.

Cardiac MRI can identify the hemodynamic changes of tamponade (collapse of the cardiac

Emergency pericardiocentesis represents the method used to relieve tamponade. Improvement of the blood pressure and cardiac output can be the result of removal even a small amount of

Emergency pericardiocentesis is the procedure used for the aspiration of the fluid from the pericardial space in patients with significant pericardial effusion, which determines hemody-

fluid (except of the cases of purulent or malignant pericardial effusions).

widen mediastinal shadow on chest radiography [16]**.**

and relatively increase of the atrial component (A wave velocity).

lar outflow tract, there is an increase of peak velocity.

Cardiac CT can identify the collapse of the cardiac chambers.

wave and high reversal during expiration.

• Pulmonary veins: decrease of D wave velocity during inspiration.

as follows [1–3, 9, 10, 12–15].

inspiration.

*2.5.4. Cardiac CT*

*2.5.5. Cardiac MRI*

chambers).

**2.6. Treatment**

**3.1. Definition**

**3. Pericardiocentesis**

namic compromise (cardiac tamponade).

Cardiac tamponade occurring after open-heart surgery is suspected in case of signs of low cardiac output, fall in systemic blood pressure associated with tachycardia and increased

**Figure 1.** Tamponade, collapse of the right ventricle free wall (echocardiography—subcostal view).

filling pressure, oliguria, decrease of chest drainage, pulsus paradoxus, cardiac arrest, and widen mediastinal shadow on chest radiography [16]**.**

Doppler echocardiography is another useful tool for diagnosis of tamponade, showing large variations with respiration (more than 30%) in the amplitude of inflow and outflow signals, as follows [1–3, 9, 10, 12–15].


Although there are many echocardiographic signs, none of these findings are entirely diagnostic of cardiac tamponade, so the diagnosis is based on both clinical and ultrasound assessment.

#### *2.5.4. Cardiac CT*

effusion. Emergency echocardiographic assessment of tamponade includes two stages: first stage demonstrates the presence of pericardial fluid collection and the second stage assesses the hemodynamic effects of previously detected collection [12]. The first sign of hemodynamic impairment in tamponade is collapse of the right ventricle free wall in early- to mid-diastole because of the increased intrapericardial pressure more than ventricular transmural distending pressure, and is very specific (**Figure 1**). Right atrial collapse appears in late diastole and has high specificity. The absence of the right chamber collapse is present in cases of elevated diastolic pressure in the right chambers, such as pulmonary hypertension, positive pressure ventilation, or severe left ventricle failure [9]. When tamponade progresses, left atrial late-diastolic collapse and left ventricle early-diastolic collapse can appear. Dilatation of inferior vena cava without normal inspiratory variation (less than 50% decrease in diameter during inspiration), known as inferior vena cava plethora, has also high sensitivity for cardiac tamponade. Other signs are swinging heart, respiratory variation in ventricular chamber size, pseudosystolic anterior motion of the mitral valve, fluttering of the ventricular septum, and dilated hepatic veins [1–4, 10, 12–15]. The absence of the heart chamber collapse is considered as a negative predictive

Cardiac tamponade occurring after open-heart surgery is suspected in case of signs of low cardiac output, fall in systemic blood pressure associated with tachycardia and increased

**Figure 1.** Tamponade, collapse of the right ventricle free wall (echocardiography—subcostal view).

sign for cardiac tamponade [9].

78 Bedside Procedures

Cardiac CT can identify the collapse of the cardiac chambers.

#### *2.5.5. Cardiac MRI*

Cardiac MRI can identify the hemodynamic changes of tamponade (collapse of the cardiac chambers).

#### **2.6. Treatment**

Emergency pericardiocentesis represents the method used to relieve tamponade. Improvement of the blood pressure and cardiac output can be the result of removal even a small amount of fluid (except of the cases of purulent or malignant pericardial effusions).

#### **3. Pericardiocentesis**

#### **3.1. Definition**

Emergency pericardiocentesis is the procedure used for the aspiration of the fluid from the pericardial space in patients with significant pericardial effusion, which determines hemodynamic compromise (cardiac tamponade).

Pericardiotomy was first performed in 1815, and the subxiphoid approach was first described in 1911. The ultrasound-guided pericardiocentesis is considered the standard procedure because of lower rate of complications.

#### **3.2. Indications**

Pericardiocentesis is indicated in hemodynamic-unstable children with cardiac tamponade and to diagnose the cause of the presence of a pericardial fluid accumulation.

#### **3.3. Contraindications**

There are relative contraindications such as uncorrected bleeding disorders, anticoagulation therapy, thrombocytopenia, small pericardial effusion with posterior localization, and aortic dissection.

**3.5. Technique**

**Figure 2.** Equipment for pericardiocentesis.

*3.5.1. Preparation*

the procedure [17, 18].

approach failure or consecutive complications.

to be done by infiltration with 1% lidocaine.

All equipment must be prepared before starting the procedure and full resuscitation equipment including defibrillator must be available. The patient must be attached to a cardiac monitor and must have an IV line in place. Sedation is necessary in patients who are awake. In patients who are unresponsive, sedation can produce hemodynamic or respiratory deterioration. It is also necessary to assure the availability for operating room in case of anatomic

Emergency Pericardiocentesis in Children http://dx.doi.org/10.5772/intechopen.70700 81

Position at 45° can bring the heart closer to the thoracic anterior wall and is preferred in patients with stable clinical conditions. In case of distended abdomen, a nasogastric tube should be put in place. The platelet count and coagulation profile should be checked before

Sterile skin preparation and area disinfection are effectuated using betadine or other antiseptic substance, and sterile fields are used to isolate this area. Local anesthesia is recommended

#### **3.4. Equipment for pericardiocentesis**


**Figure 2.** Equipment for pericardiocentesis.

#### **3.5. Technique**

Pericardiotomy was first performed in 1815, and the subxiphoid approach was first described in 1911. The ultrasound-guided pericardiocentesis is considered the standard procedure

Pericardiocentesis is indicated in hemodynamic-unstable children with cardiac tamponade

There are relative contraindications such as uncorrected bleeding disorders, anticoagulation therapy, thrombocytopenia, small pericardial effusion with posterior localization, and aortic

and to diagnose the cause of the presence of a pericardial fluid accumulation.

because of lower rate of complications.

**3.4. Equipment for pericardiocentesis**

• Resuscitation equipment including defibrillator

• Ultrasound machine (**Figure 2**)

**3.2. Indications**

80 Bedside Procedures

dissection.

**3.3. Contraindications**

• Cardiac monitor

• Antiseptic substances

• Local anesthetic

• Catheter guide

• Seldinger wire

• Pigtail catheter

• Alligator clamps

• Collection system

• Sterile compressor for transducer

• Drain tubes

• Sterile fields

• Compresses

• Needles

• Syringes

• ECG machine

#### *3.5.1. Preparation*

All equipment must be prepared before starting the procedure and full resuscitation equipment including defibrillator must be available. The patient must be attached to a cardiac monitor and must have an IV line in place. Sedation is necessary in patients who are awake. In patients who are unresponsive, sedation can produce hemodynamic or respiratory deterioration. It is also necessary to assure the availability for operating room in case of anatomic approach failure or consecutive complications.

Position at 45° can bring the heart closer to the thoracic anterior wall and is preferred in patients with stable clinical conditions. In case of distended abdomen, a nasogastric tube should be put in place. The platelet count and coagulation profile should be checked before the procedure [17, 18].

Sterile skin preparation and area disinfection are effectuated using betadine or other antiseptic substance, and sterile fields are used to isolate this area. Local anesthesia is recommended to be done by infiltration with 1% lidocaine.

#### *3.5.2. Anatomic approach*

Three main approaches such as the subxiphoid approach, parasternal approach, and apical approach are used, which are selected based on imaging guidance to find the maximum layer of effusion and avoiding the puncture of other structures [2, 10, 17–19].

*Subxiphoid (subcostal) approach* was preferred for a long period of time and is the safest approach in cases without ultrasound guidance. The needle is inserted between the xiphoid process and the left costal margin at an angle of 30–45° to the skin, and is directed toward the left shoulder (**Figures 3** and **4**).

*Parasternal approach*: the needle is placed perpendicular to the skin in the fifth intercostal parasternal space, at 1–3 cm to the sternal border (to avoid the puncture of internal mammary artery). The needle is placed into the intercostal space above the superior edge of the rib (in order to avoid the neurovascular bundle, which is located inferiorly). The risk for pneumothorax is higher than using other approaches.

*Apical approach*: the needle is introduced 1 cm lateral to the apex beat or at the edge of cardiac dullness and is directed toward the right shoulder.

> In both subxiphoid and sternal approaches, preferable patient's position is sitting at 45° angle, if the clinical condition permits, while supine position is used in patients with severe clinical

> > High risk for hepatic, gastric, phrenic,

Emergency Pericardiocentesis in Children http://dx.doi.org/10.5772/intechopen.70700 83

and diaphragmatic damage

High risk for pneumothorax and internal thoracic vessels injury

Avoid in emergency situations

The advantages and disadvantages of these approaches are presented in **Table 2** [17, 21].

**Approach Advantages Disadvantages**

Left ventricle has thick walls and protects against

No pleura near the apex and low risk of pneumothorax

**Figure 4.** Echocardiographic-guided pericardiocentesis: needle insertion.

Subxiphoid The safest approach in unguided-pericardiocentesis Low risk of pleural injury

Parasternal Echocardiography provides good visualization of the zone of maximum pericardial collection

Apical Lower risk of bleeding because of the paucity of cardiac vascularization near the heart apex

puncture

**Table 2.** Pericardiocentesis approaches.

Emergency pericardiocentesis in children is recommended to be performed under echocardiographic guide. Blind pericardiocentesis is performed only in very rare situations, which

are immediate life-threatening, because of the major risk for severe complications.

condition [17, 20].

*3.5.3. Procedure*

**Figure 3.** Echocardiographic-guided pericardiocentesis using the subxiphoid approach.

**Figure 4.** Echocardiographic-guided pericardiocentesis: needle insertion.

In both subxiphoid and sternal approaches, preferable patient's position is sitting at 45° angle, if the clinical condition permits, while supine position is used in patients with severe clinical condition [17, 20].

The advantages and disadvantages of these approaches are presented in **Table 2** [17, 21].


**Table 2.** Pericardiocentesis approaches.

#### *3.5.3. Procedure*

*3.5.2. Anatomic approach*

82 Bedside Procedures

left shoulder (**Figures 3** and **4**).

thorax is higher than using other approaches.

diac dullness and is directed toward the right shoulder.

**Figure 3.** Echocardiographic-guided pericardiocentesis using the subxiphoid approach.

Three main approaches such as the subxiphoid approach, parasternal approach, and apical approach are used, which are selected based on imaging guidance to find the maximum layer

*Subxiphoid (subcostal) approach* was preferred for a long period of time and is the safest approach in cases without ultrasound guidance. The needle is inserted between the xiphoid process and the left costal margin at an angle of 30–45° to the skin, and is directed toward the

*Parasternal approach*: the needle is placed perpendicular to the skin in the fifth intercostal parasternal space, at 1–3 cm to the sternal border (to avoid the puncture of internal mammary artery). The needle is placed into the intercostal space above the superior edge of the rib (in order to avoid the neurovascular bundle, which is located inferiorly). The risk for pneumo-

*Apical approach*: the needle is introduced 1 cm lateral to the apex beat or at the edge of car-

of effusion and avoiding the puncture of other structures [2, 10, 17–19].

Emergency pericardiocentesis in children is recommended to be performed under echocardiographic guide. Blind pericardiocentesis is performed only in very rare situations, which are immediate life-threatening, because of the major risk for severe complications.

#### *3.5.3.1. Echocardiographic-guided pericardiocentesis*

The first step of echocardiographic-guided pericardiocentesis is to assess the dimension and distribution of the pericardial fluid and the optimal trajectory of the needle in order to efficiently evacuate the pericardial fluid. The area of maximal fluid accumulation is also determined using the echocardiography. The echocardiographic transducer is covered with a sterile material (sterile glove with ultrasound sterile gel) and is positioned approximately 3–5 cm from the left parasternal border, and the area of maximal fluid accumulation is identified. The direction and trajectory of needle follows the angle of the transducer. The place of puncture is delimitated by the angle between the xiphoid process and the left costal cartilages, and 18 mm gauge needles are recommended. The distance between the skin and pericardium is about 5 cm in children. The needle is directed at a 15° posterior angle toward the shoulder and is advanced, while a continuous aspiration is performed with a syringe and the fluid is obtained. The drainage is also assessed using the echocardiography [2, 10, 17–19].

**3.6. Complications**

**3.7. Follow-up**

*Tips and tricks:*

chest pain.

pericardial fluid.

**Author details**

Cluj-Napoca, Romania

Cecilia Lazea

**References**

Complications which can occur are as follows: dysrhythmias (atrial fibrillation, ventricular tachycardia, asystole), puncture of coronary artery, hemothorax, pneumothorax, pneumopericardium, cardiac laceration, epicardial or pericardial thrombus, ventricular dysfunction, arterial hypotension because of vasovagal reaction, sudden pulmonary edema due to a sudden increase in pulmonary return, circulatory collapse in patients with an increased rate of drainage, lung laceration, intercostal vessels injury, mammary artery injury, pleuropericardic fistula, infection, diaphragm, phrenic, gastric and hepatic injury, and hemoperitoneum [2, 10, 17–21].

Emergency Pericardiocentesis in Children http://dx.doi.org/10.5772/intechopen.70700 85

After pericardiocentesis, an individualized follow-up is required. Daily echocardiographic evaluation is performed in the first few days during hospitalization to evaluate pericardial

effusion recurrence and weekly evaluation after patient discharge is required [13].

• If a large quantity of blood is aspirated, the needle could be in the ventricle.

Department of Pediatrics I, "Iuliu Hatieganu" University of Medicine and Pharmacy,

[1] Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W, Achenbach S, Agewall S, Al-Attar N, Angel Ferrer J, Arad M, Asteggiano R, Bueno H, Caforio AL, Carerj S, Ceconi C, Evangelista A, Flachskampf F,

• Clotting fluid does not reliably indicate the position of needle. • An increased rate of drainage can determine circulatory collape.

Address all correspondence to: cicilazearo@yahoo.com

• Diagnostic of cardiac tamponade is based on both clinical and ultrasound assessment.

• When the needle penetrates the pericardium, the patient who is awake can undergo a sharp

• During pericardiocentesis, the needle should not be further advanced after aspiration of

#### *3.5.3.2. Pericardiocentesis with electrocardiographic assistance*

This procedure can be used when echocardiography guiding is not available. Electrocardiogram monitoring is begun after the pericardial space has been reached, before the needle is advanced. A sterile electrical cord is attached to the needle using an alligator clips and is connected to any precordial lead in order to avoid the ventricular puncture. The electrocardiographic mark of epicardium touching is a wide complex (like a premature ventricular complex, with elevated ST segment), known as current of injury pattern. Atrial arrhythmia or PR segment elevation shows the contact with atrial pericardium, while ventricular arrhythmia is the marker of mechanical stimulation of the ventricular epicardium. The current of injury appears when the needle touches the epicardium and from this point, there is a high risk of myocardium or coronary laceration. Until the current of injury disappears, the needle must be withdrawn few millimeters and then safely placed into the pericardial space [17].

#### *3.5.3.3. Fluid aspiration*

Aspiration of pericardial fluid can increase the risk of cardiac puncture. Nonclotting aspirated blood and a lower hematocrit level may indicate a pericardial origin [17]. Diagnostic studies are performed on pericardial fluid such as cell count, protein level, glucose, lactate dehydrogenase, bacterial, fungal, and mycobacterial culture, viral PCR, and tumor cytology.

#### *3.5.3.4. Percutaneous pericardial drainage*

Insertion of a drainage catheter is used to avoid and to reduce the rate of recurrence. The subxiphoid approach is recommended using an 18-mm gauge needle. After the pericardial puncture, the position of the needle in the pericardial sac is assessed using 5–6 mL of agitated saline solution, which is injected and monitored by echocardiography, confirming the position of needle (microbubbles will create contrast into pericardial fluid). A guide wire is inserted into the pericardial space and the needle is removed, and dilatation of the needle tract is performed. Then, a pigtail catheter is inserted over the guide wire via the Seldinger technique and is left in place for few days for drainage of chronic effusions [2, 10, 13, 17, 19].

#### **3.6. Complications**

*3.5.3.1. Echocardiographic-guided pericardiocentesis*

84 Bedside Procedures

The first step of echocardiographic-guided pericardiocentesis is to assess the dimension and distribution of the pericardial fluid and the optimal trajectory of the needle in order to efficiently evacuate the pericardial fluid. The area of maximal fluid accumulation is also determined using the echocardiography. The echocardiographic transducer is covered with a sterile material (sterile glove with ultrasound sterile gel) and is positioned approximately 3–5 cm from the left parasternal border, and the area of maximal fluid accumulation is identified. The direction and trajectory of needle follows the angle of the transducer. The place of puncture is delimitated by the angle between the xiphoid process and the left costal cartilages, and 18 mm gauge needles are recommended. The distance between the skin and pericardium is about 5 cm in children. The needle is directed at a 15° posterior angle toward the shoulder and is advanced, while a continuous aspiration is performed with a syringe and the fluid is

obtained. The drainage is also assessed using the echocardiography [2, 10, 17–19].

This procedure can be used when echocardiography guiding is not available. Electrocardiogram monitoring is begun after the pericardial space has been reached, before the needle is advanced. A sterile electrical cord is attached to the needle using an alligator clips and is connected to any precordial lead in order to avoid the ventricular puncture. The electrocardiographic mark of epicardium touching is a wide complex (like a premature ventricular complex, with elevated ST segment), known as current of injury pattern. Atrial arrhythmia or PR segment elevation shows the contact with atrial pericardium, while ventricular arrhythmia is the marker of mechanical stimulation of the ventricular epicardium. The current of injury appears when the needle touches the epicardium and from this point, there is a high risk of myocardium or coronary laceration. Until the current of injury disappears, the needle must be withdrawn few millimeters and then safely placed into the pericardial space [17].

Aspiration of pericardial fluid can increase the risk of cardiac puncture. Nonclotting aspirated blood and a lower hematocrit level may indicate a pericardial origin [17]. Diagnostic studies are performed on pericardial fluid such as cell count, protein level, glucose, lactate dehydro-

Insertion of a drainage catheter is used to avoid and to reduce the rate of recurrence. The subxiphoid approach is recommended using an 18-mm gauge needle. After the pericardial puncture, the position of the needle in the pericardial sac is assessed using 5–6 mL of agitated saline solution, which is injected and monitored by echocardiography, confirming the position of needle (microbubbles will create contrast into pericardial fluid). A guide wire is inserted into the pericardial space and the needle is removed, and dilatation of the needle tract is performed. Then, a pigtail catheter is inserted over the guide wire via the Seldinger technique and is left in place for few days for drainage of chronic effusions [2, 10, 13, 17, 19].

genase, bacterial, fungal, and mycobacterial culture, viral PCR, and tumor cytology.

*3.5.3.2. Pericardiocentesis with electrocardiographic assistance*

*3.5.3.3. Fluid aspiration*

*3.5.3.4. Percutaneous pericardial drainage*

Complications which can occur are as follows: dysrhythmias (atrial fibrillation, ventricular tachycardia, asystole), puncture of coronary artery, hemothorax, pneumothorax, pneumopericardium, cardiac laceration, epicardial or pericardial thrombus, ventricular dysfunction, arterial hypotension because of vasovagal reaction, sudden pulmonary edema due to a sudden increase in pulmonary return, circulatory collapse in patients with an increased rate of drainage, lung laceration, intercostal vessels injury, mammary artery injury, pleuropericardic fistula, infection, diaphragm, phrenic, gastric and hepatic injury, and hemoperitoneum [2, 10, 17–21].

#### **3.7. Follow-up**

After pericardiocentesis, an individualized follow-up is required. Daily echocardiographic evaluation is performed in the first few days during hospitalization to evaluate pericardial effusion recurrence and weekly evaluation after patient discharge is required [13].

#### *Tips and tricks:*


## **Author details**

Cecilia Lazea

Address all correspondence to: cicilazearo@yahoo.com

Department of Pediatrics I, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania

#### **References**

[1] Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristić AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W, Achenbach S, Agewall S, Al-Attar N, Angel Ferrer J, Arad M, Asteggiano R, Bueno H, Caforio AL, Carerj S, Ceconi C, Evangelista A, Flachskampf F,

Giannakoulas G, Gielen S, Habib G, Kolh P, Lambrinou E, Lancellotti P, Lazaros G, Linhart A, Meurin P, Nieman K, Piepoli MF, Price S, Roos-Hesselink J, Roubille F, Ruschitzka F, Sagristà Sauleda J, Sousa-Uva M, Uwe Voigt J, Luis Zamorano J. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. European Heart Journal. 2015;**36**(42):2921-2964. DOI: 10.1093/eurheartj/ehv318

(EACVI) position paper: Multimodality imaging in pericardial disease. European Heart

Emergency Pericardiocentesis in Children http://dx.doi.org/10.5772/intechopen.70700 87

[14] Leeson P, Becher H. Pericardial effusion and cardiac tamponade. In: Zamorano JL, Bax J, Knuuti J, Sechtem U, Lancellotti P, Badano L, editors. The ESC Textbook of Cardiovascular Imaging. 2nd ed. New York: Oxford University Press; 2015. p. 509-519

[15] Gaspar HA, Morhy S. The role of focused echocardiography in pediatric intensive care: A critical appraisal. BioMed Research International. 2015. DOI: 10.1155/2015/596451 [16] Shah P. Manual of Pediatric Cardiac Intensive Care. 1st ed. New Delhi: Jaypee Brothers

[17] Harper R. Pericardiocentesis. In: Roberts J, Hedges J, editors. Clinical Procedures in

[18] Synovitz C, Brown E. Pericardiocentesis. In: Tintinalli J, Stapczynski S, Ma J, Yealy D, Meckler G, Cline D, editors. Tintinalli's Emergency Medicine: A Comprehensive Study

[19] Gewitz M, Satou G, Wheeler D. Diseases of the pericardium. In: Wheeler D, Wong H, Shanley T, editors. Pediatric Critical Care Medicine. Basic Science and Clinical Evidence.

[20] Gluer R, Murdoch D, Haqqani M, Scalia G, Walters D. Pericardiocentesis—How to do it. Heart, Lung & Circulation. 2015;**24**(6):621-625. DOI: 10. 1016/j.hlc.2014.11.009

[21] Kumar R. Complications of pericardiocentesis: A clinical synopsis. International Journal of Critical Illness and Injury Science. 2015;**5**(3):206-212. DOI: 10.4103/2229-5151.165007

Emergency Medicine. 4th ed. Philadelphia: Saunders; 2004. p. 305-322

Journal. Cardiovascular Imaging. 2015;**16**(1):12-31. DOI: 10.1093/ehjci/jeu128

Medical Publishers Ltd; 2013. 159 p

Guide. 8th ed. USA: McGraw-Hill; 2016. p. 236-242

1st ed. London: Springer-Verlag; 2007. p. 821-828


(EACVI) position paper: Multimodality imaging in pericardial disease. European Heart Journal. Cardiovascular Imaging. 2015;**16**(1):12-31. DOI: 10.1093/ehjci/jeu128

[14] Leeson P, Becher H. Pericardial effusion and cardiac tamponade. In: Zamorano JL, Bax J, Knuuti J, Sechtem U, Lancellotti P, Badano L, editors. The ESC Textbook of Cardiovascular Imaging. 2nd ed. New York: Oxford University Press; 2015. p. 509-519

Giannakoulas G, Gielen S, Habib G, Kolh P, Lambrinou E, Lancellotti P, Lazaros G, Linhart A, Meurin P, Nieman K, Piepoli MF, Price S, Roos-Hesselink J, Roubille F, Ruschitzka F, Sagristà Sauleda J, Sousa-Uva M, Uwe Voigt J, Luis Zamorano J. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. European Heart

[2] Tissot C, Phelps C, da Cruz E, Miyamoto S. Pericardial diseases. In: Munoz R, Morrel V, da Cruz E, Vetterly C, editors. Critical Care of Children with Heart Disease. 1st ed.

[3] Johnson J, Cetta F. Pericardial diseases. In: Allen H, Driscoll D, Shaddy R, Feltes T, editors. Moss and Adams' Heart Disease in Infants, Children, and Adolescents Including the Fetus and Young Adult. 8th ed. Philadelphia: Lippincott Williams & Wilkins, Wolters

[4] American Heart Association. Pediatric Advanced Life Support. USA: First American

[5] Arabi MT, Malek EM, Fares MH, Itani MH. Cardiac tamponade as the first manifestation of lupus erithematosus in children. BMJ Case Reports. 2012; DOI: 10.1136/

[6] Simbre VC, Duffy SA, Dadlani GH, Miller TL, Lipshultz SE. Cardiotoxicity of cancer

[7] Goldenberg J, Pessoa AP, Roizenblatt S, Pavoa RM, Hilario MO, Atra E, Ferraz MB. Cardiac tamponade in juvenile chronic arthritis: Report of two cases and review of pub-

[8] Akikusa JD. Rheumatologic emergencies in newborns, children, and adolescents. Pediatric Clinics of North America. 2012;**59**(2):285-299. DOI: 10.1016/j.pcl.2012.03.001 [9] Perez-Casares A, Cesar S, Brunet-Garcia L, Sanchez-de-Toledo J. Echocardiographic evaluation of pericardial effusion and cardiac tamponade. Frontiers in Pediatrics. 2017.

[10] Tissot C. Pericardial Diseases. In: Da Cruz E, Ivy D, Jaggers J, editors. Pediatric and Congenital Cardiology, Cardiac Surgery and Intensive Care. 1st ed. London: Springer-

[11] Johnson W, Moller J. Pediatric Cardiology. The Essential Pocket Guide. 3rd ed. Oxford:

[12] Tavazzi G, Price S. Ecocardiography in the intensive care unit. In: Berstein A, Soni N, editors. OH's Intensive Care Manual. 7th ed. China: Elsevier; 2014. p. 308-323

[13] Cosyns B, Plein S, Nihoyanopoulos P, Smiseth O, Achenbach S, Andrade MJ, Pepi M, Ristic A, Imazio M, Paelinck B, Lancellotti P, European Association of Cardiovascular Imaging (EACVI); European Society of Cardiology Working Group (ESC WG) on Myocardial and Pericardial diseases. European Association of Cardiovascular Imaging

chemotherapy: Implications for children. Paediatric Drugs. 2005;**7**(3):187-202

lications. Annals of the Rheumatic Diseases. 1990;**49**(7):549-553

Verlag; 2014. p. 2369-2394. DOI: 10.1007/978-1-4471-4619-3

London: Springer-Verlag; 2010. p. 521-541. DOI: 10.1007/978-1-84882-262-7

Journal. 2015;**36**(42):2921-2964. DOI: 10.1093/eurheartj/ehv318

Kluwer; 2013. p. 1350-1362

DOI: 10.3389/fped.2017.00079

Wiley Blackwell; 2014. 392 p

bcr-2012-006927

86 Bedside Procedures

Heart Association Printing; 2016. p. 352


**Chapter 5**

Provisional chapter

**Lumbar Puncture of the Newborn**

Lumbar Puncture of the Newborn

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

patient is having meningitis and start empirical therapy.

puncture for therapeutic, and subsequently, diagnostic purposes.

puncture, should be started immediately if lumbar puncture is to be delayed.

Keywords: infants, neonate, newborns, lumbar puncture, spinal tap, meningitis

It seems that Heinrich Irenäus Quincke was the first person in medical history to use lumbar

Empirical antibiotic therapy for suspected meningitis, which should ideally succeed lumbar

© The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Heinrich Irenäus Quincke was the first person in medical history to perform lumbar puncture (LP). Indications of lumbar puncture include suspected meningitis, suspected subarachnoid hemorrhage, administration of chemotherapeutic agents, instillation of contrast media for imaging of the spinal cord, and the evaluation of various neurologic conditions including normal pressure hydrocephalus and Guillain-Barré syndrome, and the treatment of idiopathic intracranial hypertension. Contraindications of lumbar puncture include findings of increased intracranial pressure, bleeding diathesis, cardiopulmonary instability, soft tissue infection at the puncture site, shock, respiratory insufficiency, and suspected meningococcal septicemia with extensive or spreading purpura. Altered mental status, focal neurologic signs, papilledema, focal seizure, and risk for brain abscess are indications for cranial imaging before performing LP. Lack of local anesthetic use and advancement of the spinal needle with the stylet in place were most prominent risk factors for a traumatic LP. Ultrasound may minimize the number of LP attempts and decrease patient and parent anxiety by easily identifying an insertion site. Infection, spinal hematoma, epidermoid tumor, and cerebral herniation are the main complications of LP. When LP is traumatic, the wisest approach is to assume the

DOI: 10.5772/intechopen.70498

http://dx.doi.org/10.5772/intechopen.70498

Selim Öncel

Selim Öncel

Core tips

Abstract

## **Chapter 5**

Provisional chapter

## **Lumbar Puncture of the Newborn**

Lumbar Puncture of the Newborn

## Selim Öncel

Additional information is available at the end of the chapter Selim Öncel

http://dx.doi.org/10.5772/intechopen.70498 Additional information is available at the end of the chapter

Abstract

Heinrich Irenäus Quincke was the first person in medical history to perform lumbar puncture (LP). Indications of lumbar puncture include suspected meningitis, suspected subarachnoid hemorrhage, administration of chemotherapeutic agents, instillation of contrast media for imaging of the spinal cord, and the evaluation of various neurologic conditions including normal pressure hydrocephalus and Guillain-Barré syndrome, and the treatment of idiopathic intracranial hypertension. Contraindications of lumbar puncture include findings of increased intracranial pressure, bleeding diathesis, cardiopulmonary instability, soft tissue infection at the puncture site, shock, respiratory insufficiency, and suspected meningococcal septicemia with extensive or spreading purpura. Altered mental status, focal neurologic signs, papilledema, focal seizure, and risk for brain abscess are indications for cranial imaging before performing LP. Lack of local anesthetic use and advancement of the spinal needle with the stylet in place were most prominent risk factors for a traumatic LP. Ultrasound may minimize the number of LP attempts and decrease patient and parent anxiety by easily identifying an insertion site. Infection, spinal hematoma, epidermoid tumor, and cerebral herniation are the main complications of LP. When LP is traumatic, the wisest approach is to assume the patient is having meningitis and start empirical therapy.

DOI: 10.5772/intechopen.70498

Keywords: infants, neonate, newborns, lumbar puncture, spinal tap, meningitis

## Core tips

It seems that Heinrich Irenäus Quincke was the first person in medical history to use lumbar puncture for therapeutic, and subsequently, diagnostic purposes.

Empirical antibiotic therapy for suspected meningitis, which should ideally succeed lumbar puncture, should be started immediately if lumbar puncture is to be delayed.

© The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

Lumbar puncture should always be performed as soon as the infant becomes clinically stable and can tolerate the procedure even if it has not been possible to be performed at the first suspicion of meningitis.

the spinal cord in thoracic D1–D2 interspace, most probably in the epidural space not

Lumbar Puncture of the Newborn

91

http://dx.doi.org/10.5772/intechopen.70498

• Heinrich Irenäus Quincke (1842–1922), a German professor of internal medicine in Kiel, presented his first communication on LP in the "X. Kongress der Gesellschaft für inneren Medizin" (X. Congress of the Society of Internal Medicine) in Wiesbaden, Germany on April 8, 1891. In his first procedure of its kind, Quincke used a hollow needle with stiletto, which very closely resembles the LP needles that are routinely used today. He entered the subarachnoid space at the L3-L4 intervertebral level and drained CSF with the purpose of relieving headache, suffered by children with hydrocephalus. Quincke coined the term

• According to English physician Walter Essex Wynter's (1860–1945) article published in the Lancet on May 2, 1891, he made a skin incision at the second lumbar vertebra, and then made a big opening up to the dura mater, in addition to which laminectomy was often required. Next, he introduced a trochar and took CSF out for decreasing CSF pressure.

It is clearly seen that all three investigators have done the procedure for therapeutic, not diagnostic purposes, which is the main difference from today's LP. It is also obvious that Corning's performance involves a site (thoracic) and an intermeningeal space (epidural) that

Although some authors mention the names of Corning and Wynter, it seems that Quincke was the first person in medical history to use LP for therapeutic, and subsequently, diagnostic purposes. Putting the common point of therapeutic use apart, during the time of publication, characteristics of puncture and nomenclature used were compared; we, in agreement with authors like Frederiks and Koehler, favor Quincke as the discoverer of LP. Besides, we believe that he deserves this title for being the first investigator to apply LP for diagnostic purposes

• The main indication for LP in newborn period is suspected central nervous system (CNS) infection. LP is an indispensable and emergent tool in the diagnosis of neonatal meningitis and should ideally precede the initiation of empirical antimicrobial therapy. If LP should be delayed or cannot be performed for any reason, such as deteriorating clinical status of the patient or transferring the patient to another health institution, empirical antibiotic therapy should be started immediately, since minutes count in the diagnosis and early

Clinical findings of neonatal meningitis are similar to those of neonatal sepsis with or without meningitis. Thus, it is not possible to predict with physical findings alone whether the infant has sepsis, meningitis, or both. Although signs of sepsis and meningitis intertwine in the newborn period, some neonatologist deem it unnecessary to perform LP on neonates evaluated for sepsis, especially those with early neonatal sepsis [4, 5], because the antibiotics for

"Lumbalpunction" (LP) in his subsequent paper on this field.

Wynter used the term "paracentesis" for his procedure.

removing any CSF.

is very distinct from LP.

thereafter [1, 2].

3. Indications

commencement of therapy [3].

Lumbar puncture can be performed safely in patients with thrombocytopenia less than 10,000/μL, if they receive transfusion to a peripheral platelet count greater than 50,000/μL, and in patients with coagulopathy after appropriate correction of factor deficiency.

Physicians may have to treat suspected meningitis being deprived of cerebrospinal fluid (CSF) analysis guidance, since getting parental consent for lumbar puncture may be problematic.

During lumbar puncture, airway and resuscitation equipment should be immediately at hand.

Lumbar puncture in children younger than 12 months must be performed below the L2-L3 interspace.

The presence of a family member was found to be associated with neither an increased risk of traumatic or unobtainable lumbar puncture nor more attempts at the procedure.

The "ideal" angle for lumbar puncture as determined with ultrasonography was 50 in infants in both the lateral recumbent and sitting positions.

When lumbar puncture is traumatic, the wisest approach is to assume the patient as having meningitis and start empirical therapy.

#### 1. Introduction

Lumbar puncture (LP) may be considered one of the most well-known diagnostic procedures in the field of pediatric infectious diseases. It is an essential procedure for analyzing cerebrospinal fluid (CSF) in the evaluation for meningitis, sepsis, fever, or subarachnoid hemorrhage (SAH) in neonates.

#### 2. History

Our knowledge of meninges dates back to ancient Egypt, where it was described in Ebers papyrus around 1500 BC. Hippocrates (and his physician contemporaries) must have been aware of the presence of CSF, since he is known to have referred to hydrocephalus as "water in the head."

Despite, apparently, a long time has passed since the discovery of CSF, its usual collection technique, called lumbar puncture, has a relatively short history—about only a century long. The answer to the question of who has performed the first lumbar puncture is still a little matter of debate today:

• In 1885, North-American neurologist Leonard Corning (1855–1923) published two articles, in which he described the application of "local medication" cocaine for local anesthesia to the spinal cord in thoracic D1–D2 interspace, most probably in the epidural space not removing any CSF.


It is clearly seen that all three investigators have done the procedure for therapeutic, not diagnostic purposes, which is the main difference from today's LP. It is also obvious that Corning's performance involves a site (thoracic) and an intermeningeal space (epidural) that is very distinct from LP.

Although some authors mention the names of Corning and Wynter, it seems that Quincke was the first person in medical history to use LP for therapeutic, and subsequently, diagnostic purposes. Putting the common point of therapeutic use apart, during the time of publication, characteristics of puncture and nomenclature used were compared; we, in agreement with authors like Frederiks and Koehler, favor Quincke as the discoverer of LP. Besides, we believe that he deserves this title for being the first investigator to apply LP for diagnostic purposes thereafter [1, 2].

## 3. Indications

Lumbar puncture should always be performed as soon as the infant becomes clinically stable and can tolerate the procedure even if it has not been possible to be performed at the first

Lumbar puncture can be performed safely in patients with thrombocytopenia less than 10,000/μL, if they receive transfusion to a peripheral platelet count greater than 50,000/μL, and in patients

Physicians may have to treat suspected meningitis being deprived of cerebrospinal fluid (CSF) analysis guidance, since getting parental consent for lumbar puncture may be problematic.

During lumbar puncture, airway and resuscitation equipment should be immediately at hand. Lumbar puncture in children younger than 12 months must be performed below the L2-L3

The presence of a family member was found to be associated with neither an increased risk of

The "ideal" angle for lumbar puncture as determined with ultrasonography was 50 in infants

When lumbar puncture is traumatic, the wisest approach is to assume the patient as having

Lumbar puncture (LP) may be considered one of the most well-known diagnostic procedures in the field of pediatric infectious diseases. It is an essential procedure for analyzing cerebrospinal fluid (CSF) in the evaluation for meningitis, sepsis, fever, or subarachnoid hemorrhage

Our knowledge of meninges dates back to ancient Egypt, where it was described in Ebers papyrus around 1500 BC. Hippocrates (and his physician contemporaries) must have been aware of the presence of CSF, since he is known to have referred to hydrocephalus as "water in

Despite, apparently, a long time has passed since the discovery of CSF, its usual collection technique, called lumbar puncture, has a relatively short history—about only a century long. The answer to the question of who has performed the first lumbar puncture is still a little

• In 1885, North-American neurologist Leonard Corning (1855–1923) published two articles, in which he described the application of "local medication" cocaine for local anesthesia to

traumatic or unobtainable lumbar puncture nor more attempts at the procedure.

with coagulopathy after appropriate correction of factor deficiency.

in both the lateral recumbent and sitting positions.

meningitis and start empirical therapy.

suspicion of meningitis.

90 Bedside Procedures

interspace.

1. Introduction

(SAH) in neonates.

2. History

the head."

matter of debate today:

• The main indication for LP in newborn period is suspected central nervous system (CNS) infection. LP is an indispensable and emergent tool in the diagnosis of neonatal meningitis and should ideally precede the initiation of empirical antimicrobial therapy. If LP should be delayed or cannot be performed for any reason, such as deteriorating clinical status of the patient or transferring the patient to another health institution, empirical antibiotic therapy should be started immediately, since minutes count in the diagnosis and early commencement of therapy [3].

Clinical findings of neonatal meningitis are similar to those of neonatal sepsis with or without meningitis. Thus, it is not possible to predict with physical findings alone whether the infant has sepsis, meningitis, or both. Although signs of sepsis and meningitis intertwine in the newborn period, some neonatologist deem it unnecessary to perform LP on neonates evaluated for sepsis, especially those with early neonatal sepsis [4, 5], because the antibiotics for both conditions would be the same. However, it should be kept in mind that blood cultures are negative in one-third of neonates with meningitis who are very-low-birth-weight and born over 34 weeks of gestation [6]. Thus, in case of LP is not performed, a significant portion of neonates with meningitis would not get a correct diagnosis and would not be observed for the likely complications of meningitis. For that reason, the author is in favor of the opinion that LP should always be performed as soon as the infant becomes clinically stable and can tolerate the procedure even if it has not been possible to be performed at the first suspicion of meningitis. CSF inflammation lasts for a considerably long duration of days, which would allow the clinician to diagnose or exclude the diagnosis of meningitis although CSF cultures may become negative within hours.

normalized ratio of 1.4 or higher, without correcting the underlying abnormalities [8, 10]. However, LP can be performed safely in patients with thrombocytopenia less than 10,000/μL, if they receive transfusion to a peripheral platelet count greater than 50,000/μL, and in patients

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• Cardiopulmonary instability: The position of the newborn during LP may result in cardiopulmonary compromise. This issue will be addressed further in detail elsewhere in the

Conditions listed below are conditions in which imaging is needed before LP to exclude brain

• Moderate to severe impairment of consciousness [Glascow coma scale (GCS) < 13 or 9

Consequently, LP is sometimes contraindicated simply because the patient is too ill to safely

Since patients without appropriate decisional capacity cannot give their informed consent and written informed consent of the caregiver is required before the procedure, in many institutions including ours, it is customary for physicians to talk to parents for providing informed permission for an intervention like LP on their child. A straightforward explanation of the urgency and essentialness of the procedure, as well as the details of the procedure itself, maybe with the help of comparison with usual venipuncture (author's practice), is usually reassuring and should routinely be provided. Sometimes parents refuse to give assent and physicians are forced to initiate and continue CNS infection treatment totally blindfolded—that is without

• Suspected meningococcal septicemia with extensive or spreading purpura [10]

• Focal neurological signs (including unequal, dilated, or poorly responsive pupils)

with coagulopathy after appropriate correction of factor deficiency [9, 11].

text.

• Shock

• Soft tissue infection at the puncture site

shift, swelling, or space occupying lesion [10]:

• Abnormal posture or posturing

• After seizures until stabilized

• Immunocompromise

undergo the procedure.

5. Parental consent

• Relative bradycardia with hypertension

• Abnormal "doll's eye" movements

• Papilledema

according to some experts] or fall in GCS of >2

• Respiratory insufficiency


## 4. Contraindications

A contraindication to LP can be absolute or relative. In all situations, the clinician should use her/his clinical judgment by taking into account the relative risk of performing LP.


Because of the risk of subdural or epidural hematoma formation, many experts are against performing LP in patients with coagulation defects who are bleeding, severely thrombocytopenic (i.e., with platelet counts <50,000/μL), receiving anticoagulant therapy or an international normalized ratio of 1.4 or higher, without correcting the underlying abnormalities [8, 10]. However, LP can be performed safely in patients with thrombocytopenia less than 10,000/μL, if they receive transfusion to a peripheral platelet count greater than 50,000/μL, and in patients with coagulopathy after appropriate correction of factor deficiency [9, 11].


both conditions would be the same. However, it should be kept in mind that blood cultures are negative in one-third of neonates with meningitis who are very-low-birth-weight and born over 34 weeks of gestation [6]. Thus, in case of LP is not performed, a significant portion of neonates with meningitis would not get a correct diagnosis and would not be observed for the likely complications of meningitis. For that reason, the author is in favor of the opinion that LP should always be performed as soon as the infant becomes clinically stable and can tolerate the procedure even if it has not been possible to be performed at the first suspicion of meningitis. CSF inflammation lasts for a considerably long duration of days, which would allow the clinician to diagnose or exclude the diagnosis of meningitis although CSF cultures may

• Suspected subarachnoid hemorrhage (SAH) is another emergent indication for LP. Computed tomography (CT) should be performed for all children suspected of having SAH. There are times when SAH is not detectable on a CT scan and LP becomes the sole method

• Other indications for LP include the administration of chemotherapeutic agents, instillation of contrast media for imaging of the spinal cord, and the evaluation of various neurologic conditions including normal pressure hydrocephalus and Guillain-Barré syndrome. Among therapeutic uses of LP, removal of CSF in the treatment of idiopathic

A contraindication to LP can be absolute or relative. In all situations, the clinician should use

• Increased intracranial pressure (ICP): Increased intracranial pressure (ICP) is an absolute contraindication. Children with elevated ICP are at risk for cerebral herniation during LP. Therefore, cranial CT of all patients with clinical suspicion of increased ICP is essential for the physician's decision to perform LP, including those at risk because of brain abscess [8].

• Bleeding diathesis: Our knowledge regarding the safety of performing LP in patients with thrombocytopenia or coagulation factor deficiency is limited. The safety of LP in thrombocytopenia was investigated in 5223 LPs performed on 958 children with acute lymphoblastic leukemia in a retrospective study. Of these LPs, 912 were done at platelet counts of 11,000– 20,000/μL, and 29 were performed at platelet counts of 10,000/μL or less. Serious complications of LP were not observed, regardless of platelet count. The authors concluded that prophylactic platelet transfusion was not necessary in children with platelet counts higher than 10,000/μL with a little caution that no conclusion can be made for children with platelet

counts of 10,000/μL or less, due to the small number of patients in the study [9].

Because of the risk of subdural or epidural hematoma formation, many experts are against performing LP in patients with coagulation defects who are bleeding, severely thrombocytopenic (i.e., with platelet counts <50,000/μL), receiving anticoagulant therapy or an international

her/his clinical judgment by taking into account the relative risk of performing LP.

intracranial hypertension (pseudotumor cerebri) is noteworthy [8].

become negative within hours.

92 Bedside Procedures

4. Contraindications

of diagnosing this condition [7].


Conditions listed below are conditions in which imaging is needed before LP to exclude brain shift, swelling, or space occupying lesion [10]:


Consequently, LP is sometimes contraindicated simply because the patient is too ill to safely undergo the procedure.

#### 5. Parental consent

Since patients without appropriate decisional capacity cannot give their informed consent and written informed consent of the caregiver is required before the procedure, in many institutions including ours, it is customary for physicians to talk to parents for providing informed permission for an intervention like LP on their child. A straightforward explanation of the urgency and essentialness of the procedure, as well as the details of the procedure itself, maybe with the help of comparison with usual venipuncture (author's practice), is usually reassuring and should routinely be provided. Sometimes parents refuse to give assent and physicians are forced to initiate and continue CNS infection treatment totally blindfolded—that is without being able to include or exclude the diagnosis, grow the etiologic organism, and confirm the treatment success. Although LP is a relatively safe process, results from studies show that the most frequent concern that lay behind a dissent is that LP would cause a complication [12, 13]. In a single-center study carried out in Turkey, the most feared complication was paralysis (60%) followed by sterility (22%) [14].

• identification of infants who may require sedation or topical transdermal anesthesia for

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• Lidocaine 1% without epinephrine and topical anesthetic cream, such as liposomal lido-

CSF circulates in the space between the pia mater and the arachnoid mater, called subarachnoid space that surrounds the brain, spinal cord, ventricles, aqueductus cerebri (Sylvius), and central canal of the spinal cord. After the formation of most of its volume in the choroid plexuses of the lateral ventricles, CSF passes through the foramina of Luschka and Magendie into the subarachnoid space, which is around the spinal column and over the cerebrum. The CSF is primarily absorbed by the arachnoid villi found next to the sagittal sinus and then drains into the venous circulation [7, 20, 21]. In full-term infants, the volume of total CSF is about 40 mL, a quarter of which is in the ventricles, and the remainder in the subarachnoid space. CSF serves as a cushion between bony structures and the brain, together with the spinal cord. Since brain has no lymphatics, CSF also has an important role of carrying chemical

In order to avoid an accidental nervous injury, LP should be performed distal to the spinal cord, at the level of the cauda equina. In older children, LP can be performed from the L2-L3 interspace to the L5-S1 interspace, because these interspaces are below the termination of the spinal cord [8]. At birth, the inferior end of the spinal cord is opposite to the body of the third lumbar vertebra (L3); therefore, LP in children younger than 12 months must be performed below the L2-L3 interspace. As the child's spinal cord grows, the vertebral column grows more rapidly. An imaginary line that connects the two posterior-superior iliac crests intersects the spine at approximately the fourth lumbar vertebra. This landmark helps to locate the L3-L4

Materials needed for a smooth LP may be listed as follows [8]:

caine or eutectic mixture of lidocaine 2.5% and prilocaine 2.5%

• Manometer (typically used in patients older than two years of age) • 22-gauge and 1.5 inches (3.75 cm) long styletted spinal needle [7]

byproducts of metabolism out of the brain to the venous circulation [7].

• Sterile 3 mL syringe with 25-gauge needle for lidocaine injection

the procedure.

• Four sterile collecting tubes

• Povidone-iodine solution

• Resuscitation equipment

• Sterile sponges for preparing puncture site

• Sterile gloves • Sterile drapes

8. Anatomy

### 6. Imaging

The decision to carry out imaging before LP should be done on a case-by-case basis. Children with the following conditions may have increased intracranial pressure (ICP) and, because of the assumption is that CT scan of the head can more or less reliably predict who will and who will not experience brain herniation after lumbar puncture, are advised to have a CT scan performed before LP [15]:


It should be noted that a normal CT scan does not fully exclude the presence of elevated ICP or the possibility that elevated ICP will not develop thereafter. It is also known from adult studies that even those not undergoing LP because of a mass effect on head CTs may experience brain herniation [16]. Thus, although imaging for this purpose has been questioned by some specialists of this field, we agree with the recommendation that LP can be considered within 6 hours of a normal CT scan and no other contraindications [8, 17].

## 7. Preparation

Once the informed consent is obtained and imaging is performed if necessary, it is time for:


• identification of infants who may require sedation or topical transdermal anesthesia for the procedure.

Materials needed for a smooth LP may be listed as follows [8]:


being able to include or exclude the diagnosis, grow the etiologic organism, and confirm the treatment success. Although LP is a relatively safe process, results from studies show that the most frequent concern that lay behind a dissent is that LP would cause a complication [12, 13]. In a single-center study carried out in Turkey, the most feared complication was paralysis

The decision to carry out imaging before LP should be done on a case-by-case basis. Children with the following conditions may have increased intracranial pressure (ICP) and, because of the assumption is that CT scan of the head can more or less reliably predict who will and who will not experience brain herniation after lumbar puncture, are advised to have a CT scan

• Risk for brain abscess (immunocompromise or congenital heart disease with a right-to-left

It should be noted that a normal CT scan does not fully exclude the presence of elevated ICP or the possibility that elevated ICP will not develop thereafter. It is also known from adult studies that even those not undergoing LP because of a mass effect on head CTs may experience brain herniation [16]. Thus, although imaging for this purpose has been questioned by some specialists of this field, we agree with the recommendation that LP can be considered within 6 hours

Once the informed consent is obtained and imaging is performed if necessary, it is time for: • providing oxygen saturation, respirations, and heart rate (HR) monitoring for critically-ill

• "rehearsing" the position that infants will assume and getting help from a health care personnel who can hold the infant in sitting position if she/he is in respiratory distress

• getting help from a radiologist for patients with spinal abnormalities, such as spina bifida or severe scoliosis, to perform the procedure under ultrasonographic guidance [19]; and

of a normal CT scan and no other contraindications [8, 17].

(since in this position LP may be tolerated better) [18];

(60%) followed by sterility (22%) [14].

6. Imaging

94 Bedside Procedures

performed before LP [15]: • Altered mental status • Focal neurologic signs

• Papilledema • Focal seizure

shunt)

7. Preparation

children during the procedure;


#### 8. Anatomy

CSF circulates in the space between the pia mater and the arachnoid mater, called subarachnoid space that surrounds the brain, spinal cord, ventricles, aqueductus cerebri (Sylvius), and central canal of the spinal cord. After the formation of most of its volume in the choroid plexuses of the lateral ventricles, CSF passes through the foramina of Luschka and Magendie into the subarachnoid space, which is around the spinal column and over the cerebrum. The CSF is primarily absorbed by the arachnoid villi found next to the sagittal sinus and then drains into the venous circulation [7, 20, 21]. In full-term infants, the volume of total CSF is about 40 mL, a quarter of which is in the ventricles, and the remainder in the subarachnoid space. CSF serves as a cushion between bony structures and the brain, together with the spinal cord. Since brain has no lymphatics, CSF also has an important role of carrying chemical byproducts of metabolism out of the brain to the venous circulation [7].

In order to avoid an accidental nervous injury, LP should be performed distal to the spinal cord, at the level of the cauda equina. In older children, LP can be performed from the L2-L3 interspace to the L5-S1 interspace, because these interspaces are below the termination of the spinal cord [8]. At birth, the inferior end of the spinal cord is opposite to the body of the third lumbar vertebra (L3); therefore, LP in children younger than 12 months must be performed below the L2-L3 interspace. As the child's spinal cord grows, the vertebral column grows more rapidly. An imaginary line that connects the two posterior-superior iliac crests intersects the spine at approximately the fourth lumbar vertebra. This landmark helps to locate the L3-L4 and L4-L5 interspaces [8]. Anatomic structures pierced during median LP in order are skin, subcutaneous fat, supraspinal ligament, interspinal ligament, ligamentum flavum, dura mater, and arachnoid mater [7].

#### 9. Procedure

#### 9.1. Before the procedure

Most of the time, LP is a relatively simple procedure, although it can sometimes prove challenging even for the most experienced physician. The potential for complications during and following LP makes it necessary that it be performed in an area with proper resuscitation equipment. Although not technically complex, LP is not a procedure that may be taken lightly, and it should only be performed by or under the supervision of a knowledgeable and experienced health professional.

HR, respiratory action, and oxygen saturation should be monitored closely during the procedure in neonates. Airway and resuscitation equipment should be immediately at hand. If the indication for the LP is elective, or by any other reason LP is not going to be done urgently, 4% lidocaine cream (effective after about 30 minutes) or eutectic mixture of lidocaine and prilocaine (effective after about 45–60 minutes) may be applied over the puncture site to lessen the pain [22, 23]. Due to the shorter time it takes for the onset of its effect, 4% lidocaine cream may be the preferred agent for this purpose.

Figure 1. Lateral recumbent position (by Ziver Öncel).

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Figure 2. Sitting position (by Ziver Öncel).

#### 9.2. Positioning of the newborn

According to a popular saying in pediatric circles in Turkey, "the person who performs the LP is the one who holds the infant." This saying emphasizes the challenging task of achieving and maintaining a proper patient position for the performer of LP. The patient is placed on the examining table. The goals of positioning are to stabilize the infant, to stretch the ligamenta flava and to increase the interlaminar spaces. The most common positions used for the pediatric LP are the lateral recumbent and sitting positions (Figures 1 and 2). For the lateral recumbent position, the patient is laid on her/his side near the edge of the bed. For a right-handed performer, the patient's head should face left because of ergonomics of the right upper extremity of the performer. The patient's neck is flexed and the knees are drawn up to the chest by the assistant by placing one arm under the child's knees and the other arm around the posterior aspect of the neck. The assistant should ensure that the spinal column is in no rotation by keeping the shoulders and hips perpendicular to the bed.

In the sitting position, the assistant holds the patient in the position with an arm and a leg in each hand while supporting the head to prevent from dropping, that is, excess flexion of the neck.

Choosing among the lateral recumbent and sitting positions with the neck or hip flexed or neutral, has not been standardized and is at the physician's disposal, and most neonatologists prefer placing the infant in lateral recumbent position [24]. The positions are important because they may be superior over one another in avoiding a traumatic tap (peripheral blood staining the CSF specimen) and to get sufficient amount of cerebrospinal fluid, which should

Figure 1. Lateral recumbent position (by Ziver Öncel).

and L4-L5 interspaces [8]. Anatomic structures pierced during median LP in order are skin, subcutaneous fat, supraspinal ligament, interspinal ligament, ligamentum flavum, dura mater,

Most of the time, LP is a relatively simple procedure, although it can sometimes prove challenging even for the most experienced physician. The potential for complications during and following LP makes it necessary that it be performed in an area with proper resuscitation equipment. Although not technically complex, LP is not a procedure that may be taken lightly, and it should only be performed by or under the supervision of a knowledgeable and experi-

HR, respiratory action, and oxygen saturation should be monitored closely during the procedure in neonates. Airway and resuscitation equipment should be immediately at hand. If the indication for the LP is elective, or by any other reason LP is not going to be done urgently, 4% lidocaine cream (effective after about 30 minutes) or eutectic mixture of lidocaine and prilocaine (effective after about 45–60 minutes) may be applied over the puncture site to lessen the pain [22, 23]. Due to the shorter time it takes for the onset of its effect, 4% lidocaine cream

According to a popular saying in pediatric circles in Turkey, "the person who performs the LP is the one who holds the infant." This saying emphasizes the challenging task of achieving and maintaining a proper patient position for the performer of LP. The patient is placed on the examining table. The goals of positioning are to stabilize the infant, to stretch the ligamenta flava and to increase the interlaminar spaces. The most common positions used for the pediatric LP are the lateral recumbent and sitting positions (Figures 1 and 2). For the lateral recumbent position, the patient is laid on her/his side near the edge of the bed. For a right-handed performer, the patient's head should face left because of ergonomics of the right upper extremity of the performer. The patient's neck is flexed and the knees are drawn up to the chest by the assistant by placing one arm under the child's knees and the other arm around the posterior aspect of the neck. The assistant should ensure that the spinal column is in no rotation by

In the sitting position, the assistant holds the patient in the position with an arm and a leg in each hand while supporting the head to prevent from dropping, that is, excess flexion of the neck.

Choosing among the lateral recumbent and sitting positions with the neck or hip flexed or neutral, has not been standardized and is at the physician's disposal, and most neonatologists prefer placing the infant in lateral recumbent position [24]. The positions are important because they may be superior over one another in avoiding a traumatic tap (peripheral blood staining the CSF specimen) and to get sufficient amount of cerebrospinal fluid, which should

and arachnoid mater [7].

9.1. Before the procedure

enced health professional.

may be the preferred agent for this purpose.

keeping the shoulders and hips perpendicular to the bed.

9.2. Positioning of the newborn

9. Procedure

96 Bedside Procedures

Figure 2. Sitting position (by Ziver Öncel).

be feasible in a still infant with the widest interspinous space (the space between the spinous processes of two adjacent vertebrae) possible. Change of position does not alter subarachnoid space width, thus does not have a role in lumbar puncture success via this mechanism [25]. Safety, as well as the ease of the LP is a very important issue in the neonatal period especially considering the vulnerability of infants hospitalized in neonatal intensive care units. In adults, studies have uniformly showed that the maximal interspinal distance can be obtained with maximal hip flexion [26, 27].

the procedure site. The projection of interspace on the skin may be marked by depressing a

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If not previously anesthetized with one of the topical agents mentioned above, the skin and subcutaneous tissues are infiltrated with 1% lidocaine. Local anesthesia for LP is encouraged in neonates, because it has been shown to decrease the pain response to LPs without altering their

Two approaches are possible for inserting the spinal needle: in the median approach, the needle is inserted through the supraspinal ligament exactly in the midline. In the lateral approach, the needle is inserted lateral to the ligament. Unlike older patients, supraspinal and interspinal ligaments are rarely calcified in children, which renders a lateral approach unnecessary; therefore the median approach is most commonly used. With both approaches, the needle may be held in one hand or with both hands. It is better if the bevel of the spinal needle is positioned horizontally in the lateral recumbent position and vertically in the sitting position, because in this way, the fibers of the dura mater, which run longitudinally down the spinal cord, are pierced parallelly, the amount of CSF leakage is minimized, and likelihood of post-LP headache is decreased [7]. The needle is then advanced cephalad toward the umbilicus or slightly caudad according to the patient's position of lateral recumbency or sitting, respectively. In the study by Bruccoleri et al., the "ideal" angle for LP as determined by ultrasonography was 50 in infants in both the lateral recumbent and sitting positions [32]. In the lateral approach, the needle should be inserted lateral to the upper border of the spinous process of L3 or L4. It should then be directed slightly medial and slightly upward (cephalad) to avoid

It is normal that some resistance is felt during the advancement of the needle. When the ligamentum flavum is penetrated, this resistance may be lost a bit, especially in older children. There is a second resistance change when the dura is pierced. This second loss of resistance is often referred to as a "pop," which may not be evident in infants. Inserting the needle too far may result in a traumatic LP. The most effective way to avoid this problem is by inserting the needle slowly and methodically, in increments of a few millimeters at a time, and frequently checking for return of CSF. For infants under 3 months of age, the appropriate distance of insertion is approximately 1.0–1.5 cm [33]. Various studies have been carried out to determine the proper depth of needle insertion for LP. Of these studies, numerous different formulae have been developed. Taking the studies of Craig et al., Shenkman et al., Arthurs et al., and Oulego-Erroz et al., whose formulae are applicable to neonates, as examples, the ideal dis-

• [13.19 + 0.0026 weight (g) 0.12 post-conceptual age in weeks] mm,

dural tugging, a potential source of local pain and post-LP CSF leakage.

The spinal needle should be supported with fingers during fluid collection in order to prevent

fingernail on the skin so that the puncture site can be relocated.

success rate [31].

contact with the supraspinal ligament.

tances of insertion were found to be

• [2 weight (kg) + 7] mm, and

• [2.5 weight (kg) + 6] mm, respectively [34–37].

• [0.03 height (cm)] cm,

We have shown in our study, in which the infants enrolled were placed in two lateral recumbent and two upright positions (lateral recumbent without flexing the hips, lateral recumbent with maximal hip flexion, sitting without flexing the hips and sitting with maximal hip flexion), that having the patient sit with maximal hip flexion provided the largest interspinous space for the grand majority of the infants, and that the lateral recumbent position without flexing the hips has resulted in the narrowest interspinous space. Although providing significantly larger interspinous spaces, sitting positions with/without flexion have resulted in significant increases in HR with respect to lateral recumbent position without flexion. Similarly, we observed statistically significant drops in oxygen saturations between lateral recumbent and sitting with flexion, lateral recumbent with flexion and sitting without flexion, and lateral recumbent with flexion and sitting with flexion positions. No adverse hypoxic events occurred during the procedure in the entire study [28]. In adults, the position providing the significantly greatest interspinous space was obtained with the so-called "sitting, feet supported position" in which the patient touches her/his ankles while sitting [27]. This position resembles sitting with maximal hip flexion position in newborns. In a survey, most (82%) pediatric emergency attending physicians were found to opt for the lateral decubitus position [29]. Gleason et al. found that although PO2 decreased and the HR increased with each position for LP, the decrease was significantly greater in the recumbent position with maximal hip flexion [30]. Cadigan et al. also found that recumbent with maximal hip flexion position provided wider interspinous spaces than did the recumbent without flexing the hips in healthy newborns in their well-child visits [24]. HR and oxygen saturation differed significantly with positioning of the infants in our study; however, this did not result in any apparent changes in clinical status. Although there were few infants weighing less than 1500 g in our study population, our results have shown that sitting-flexed position was a safe alternative to traditional-flexed recumbent position [28].

#### 9.3. Landmarks

Once the patient is positioned, the most upper points of the posterior superior iliac crests are palpated. The line imaginarily drawn between these two points intersects the midline just above the fourth lumbar vertebra. The interspaces between L3-L4 and L4-L5 can then be located. Unlike children outside infancy, for whom the L2-L3 interspace may also be used, L3-L4 or L4-L5 interspace should be used for LP of neonates due to anatomical positioning explained above [7].

#### 9.4. Puncture

The puncture site should be cleansed with povidone-iodine solution, which can be removed with alcohol. Sterile drapes with a hole in the center to allow for a fine exposure are placed on the procedure site. The projection of interspace on the skin may be marked by depressing a fingernail on the skin so that the puncture site can be relocated.

If not previously anesthetized with one of the topical agents mentioned above, the skin and subcutaneous tissues are infiltrated with 1% lidocaine. Local anesthesia for LP is encouraged in neonates, because it has been shown to decrease the pain response to LPs without altering their success rate [31].

Two approaches are possible for inserting the spinal needle: in the median approach, the needle is inserted through the supraspinal ligament exactly in the midline. In the lateral approach, the needle is inserted lateral to the ligament. Unlike older patients, supraspinal and interspinal ligaments are rarely calcified in children, which renders a lateral approach unnecessary; therefore the median approach is most commonly used. With both approaches, the needle may be held in one hand or with both hands. It is better if the bevel of the spinal needle is positioned horizontally in the lateral recumbent position and vertically in the sitting position, because in this way, the fibers of the dura mater, which run longitudinally down the spinal cord, are pierced parallelly, the amount of CSF leakage is minimized, and likelihood of post-LP headache is decreased [7]. The needle is then advanced cephalad toward the umbilicus or slightly caudad according to the patient's position of lateral recumbency or sitting, respectively. In the study by Bruccoleri et al., the "ideal" angle for LP as determined by ultrasonography was 50 in infants in both the lateral recumbent and sitting positions [32]. In the lateral approach, the needle should be inserted lateral to the upper border of the spinous process of L3 or L4. It should then be directed slightly medial and slightly upward (cephalad) to avoid contact with the supraspinal ligament.

It is normal that some resistance is felt during the advancement of the needle. When the ligamentum flavum is penetrated, this resistance may be lost a bit, especially in older children. There is a second resistance change when the dura is pierced. This second loss of resistance is often referred to as a "pop," which may not be evident in infants. Inserting the needle too far may result in a traumatic LP. The most effective way to avoid this problem is by inserting the needle slowly and methodically, in increments of a few millimeters at a time, and frequently checking for return of CSF. For infants under 3 months of age, the appropriate distance of insertion is approximately 1.0–1.5 cm [33]. Various studies have been carried out to determine the proper depth of needle insertion for LP. Of these studies, numerous different formulae have been developed. Taking the studies of Craig et al., Shenkman et al., Arthurs et al., and Oulego-Erroz et al., whose formulae are applicable to neonates, as examples, the ideal distances of insertion were found to be

• [0.03 height (cm)] cm,

be feasible in a still infant with the widest interspinous space (the space between the spinous processes of two adjacent vertebrae) possible. Change of position does not alter subarachnoid space width, thus does not have a role in lumbar puncture success via this mechanism [25]. Safety, as well as the ease of the LP is a very important issue in the neonatal period especially considering the vulnerability of infants hospitalized in neonatal intensive care units. In adults, studies have uniformly showed that the maximal interspinal distance can be obtained with

We have shown in our study, in which the infants enrolled were placed in two lateral recumbent and two upright positions (lateral recumbent without flexing the hips, lateral recumbent with maximal hip flexion, sitting without flexing the hips and sitting with maximal hip flexion), that having the patient sit with maximal hip flexion provided the largest interspinous space for the grand majority of the infants, and that the lateral recumbent position without flexing the hips has resulted in the narrowest interspinous space. Although providing significantly larger interspinous spaces, sitting positions with/without flexion have resulted in significant increases in HR with respect to lateral recumbent position without flexion. Similarly, we observed statistically significant drops in oxygen saturations between lateral recumbent and sitting with flexion, lateral recumbent with flexion and sitting without flexion, and lateral recumbent with flexion and sitting with flexion positions. No adverse hypoxic events occurred during the procedure in the entire study [28]. In adults, the position providing the significantly greatest interspinous space was obtained with the so-called "sitting, feet supported position" in which the patient touches her/his ankles while sitting [27]. This position resembles sitting with maximal hip flexion position in newborns. In a survey, most (82%) pediatric emergency attending physicians were found to opt for the lateral decubitus position [29]. Gleason et al. found that although PO2 decreased and the HR increased with each position for LP, the decrease was significantly greater in the recumbent position with maximal hip flexion [30]. Cadigan et al. also found that recumbent with maximal hip flexion position provided wider interspinous spaces than did the recumbent without flexing the hips in healthy newborns in their well-child visits [24]. HR and oxygen saturation differed significantly with positioning of the infants in our study; however, this did not result in any apparent changes in clinical status. Although there were few infants weighing less than 1500 g in our study population, our results have shown that sitting-flexed position was

Once the patient is positioned, the most upper points of the posterior superior iliac crests are palpated. The line imaginarily drawn between these two points intersects the midline just above the fourth lumbar vertebra. The interspaces between L3-L4 and L4-L5 can then be located. Unlike children outside infancy, for whom the L2-L3 interspace may also be used, L3-L4 or L4-L5 interspace should be used for LP of neonates due to anatomical positioning explained above [7].

The puncture site should be cleansed with povidone-iodine solution, which can be removed with alcohol. Sterile drapes with a hole in the center to allow for a fine exposure are placed on

a safe alternative to traditional-flexed recumbent position [28].

maximal hip flexion [26, 27].

98 Bedside Procedures

9.3. Landmarks

9.4. Puncture


The spinal needle should be supported with fingers during fluid collection in order to prevent dural tugging, a potential source of local pain and post-LP CSF leakage.

If no CSF is coming after the needle has been inserted into an appropriate depth, rotating the needle 90 may be of help. If this is not effective, the stylet is replaced and the needle is advanced slightly. In some cases, withdrawing the needle incrementally will result in CSF flow when the procedure is initially unsuccessful. If spinal fluid is not obtained despite such maneuvers, the procedure should be attempted again by removing the spinal needle with the stylet in place till it arrives just under the skin and redirecting it. The needle can also be withdrawn entirely and a new needle used at a different insertion site. CSF may come very slowly in dehydrated infants when LP is performed using the lateral recumbent position. Getting the patient to a sitting position may increase flow in this situation.

newborns [42]. Of note, an estimation on CSF pressure can be made by counting the drops of CSF in a certain time. For 22-gauge, 1.5-inch needles recommended for use in the newborn period of life, the counting periods for which the number of drops counted equals the CSF pressure (in cm H2O) are 21 and 20 seconds for body temperatures of <40 and ≥40C, respec-

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The CSF is collected in test tubes. Approximately, 1 mL per tube is required for routine studies. The first tube specimen should be sent for Gram stain and bacterial culture, the second for quantitative glucose and protein, and the third for cell count and differential. Additional tubes may be used for viral culture, fungal culture, bacterial antigens, cell pathology, or special chemistries, if needed. After CSF collection, closing pressure may be measured as previously described. The spinal needle is removed with the stylet in place. The puncture area should be cleansed and a sterile dressing applied. It is important to remember removing the dressing

LP is frequently associated with the minor complications of localized back pain without neurologic abnormalities, transient paresthesia during the procedure, and post-LP headache,

Permanent peripheral nerve damage is rare, because the spinal needle does not pierce the

Major complications after LP include LP-induced meningitis, epidural or subdural hematoma, acquired epidermoid tumor, damage to adjacent structures (disk herniation, retroperitoneal abscess, spinal cord hematoma), and cerebral herniation. Fortunately, these complications are quite rare. As previously mentioned, in the young infant, the lateral recumbent position for LP

• Infection: LP through an area of cellulitis predictably causes meningitis. For this reason, cellulitis overlying the LP site constitutes an absolute contraindication to this procedure. An association has also been detected between performing LP in children with bacteremia and the occurrence of meningitis [44]; but in a subsequent analysis, this association was not confirmed [45]. In the absence of soft tissue infection at the puncture site, the risk of causing meningitis, epidural abscess, or osteomyelitis is rare enough to be clinically

• Spinal hematoma: Subdural or epidural hematoma following LP has been reported with all forms of bleeding diathesis. Signs and symptoms of spinal cord compression, which develops hours to days after the procedure, include sensory deficits, paralysis, and incontinence. In most cases, LP is difficult and yields bloody fluid. In these patients, platelet counts are low or falling, and platelet transfusion has not been provided before LP [7, 47].

• Epidermoid tumor: Acquired epidermal spinal cord tumors can arise 1.5–23 years after LP due to implantation of epidermal material into the spinal canal during LP. The tumor manifests itself as gait disturbance, pain, and neurologic dysfunction. Experimental and

can cause respiratory obstruction, hypoxemia, and cardiovascular instability.

after a reasonable time so that it does not become a source of infection.

all of which a newborn may fail to express in some way.

nerve, instead, it may move or stretch it [7].

tively [43].

10. Complications

insignificant [46].

If bony resistance is felt when the needle is not yet advanced into deep tissues, then puncture over the spinous process is likely, and the needle should be withdrawn till it is just below the skin and redirected through the interspace. If bony resistance is felt when it went deeper, then the likely cause is inadequate spinal flexion. Directing the needle more cephalad and improving the position usually overcomes this problem [7].

#### 9.5. Traumatic LP

Traumatic or unsuccessful LP a neonates is a probability in 30–50% of the time [38]. A traumatic LP may stem from improper technique. Causes include inserting the needle too far into an epidural venous plexus or through the subarachnoid space into or adjacent to the vertebral body. Nigrovic et al. found that lack of local anesthetic use and advancement of the spinal needle with the stylet in place were most prominent risk factors for a traumatic LP [39]. In the study of Glatstein et al., its incidence was independent of physician experience, sedation use or time of procedure [40]. It is also surprising for the author of these lines that the presence of a family member was not found to be associated with an increased risk of traumatic or unobtainable lumbar puncture, nor was it associated with more attempts at the procedure [41]. If blood is seen during fluid collection but the spinal needle is in proper position, the CSF often clears and the specimen does not clot. If the bloody CSF does not clear and clots form when it is collected in the test tube, then the needle should be removed and LP attempted at a different interspace with a new needle [7]. Ultrasound may minimize the number of LP attempts and decrease patient and parent anxiety by easily identifying an insertion site. It may also be useful to determine the reason for failure and the likelihood of success on continued attempts [19].

#### 9.6. Measurements and tests

Measurement of CSF opening pressure is recommended during any LP when possible. The infant's struggling may be an obstacle for accurate measurement of opening pressure. The measurement is most reliable in a calm patient in the lateral recumbent position. As soon as the flow of CSF stabilizes and show pressure pulses with respiration, heartbeat, and jugular occlusion, the pressure manometer is immediately attached to the needle hub via a three-way stopcock. The pressure is measured at the highest level CSF reaches. Normal CSF pressure is 5–20 cm H2O in a child with neck and legs extended and 10–28 cm H2O with neck and legs flexed [7]. However, since an adult study reached totally opposite results, it is also possible that CSF pressure does not meaningfully decrease when the lower extremities are brought to extension from flexion in newborns. Kaiser et al. found the normal range of 0–7.6 cm H2O for newborns [42]. Of note, an estimation on CSF pressure can be made by counting the drops of CSF in a certain time. For 22-gauge, 1.5-inch needles recommended for use in the newborn period of life, the counting periods for which the number of drops counted equals the CSF pressure (in cm H2O) are 21 and 20 seconds for body temperatures of <40 and ≥40C, respectively [43].

The CSF is collected in test tubes. Approximately, 1 mL per tube is required for routine studies. The first tube specimen should be sent for Gram stain and bacterial culture, the second for quantitative glucose and protein, and the third for cell count and differential. Additional tubes may be used for viral culture, fungal culture, bacterial antigens, cell pathology, or special chemistries, if needed. After CSF collection, closing pressure may be measured as previously described. The spinal needle is removed with the stylet in place. The puncture area should be cleansed and a sterile dressing applied. It is important to remember removing the dressing after a reasonable time so that it does not become a source of infection.

## 10. Complications

If no CSF is coming after the needle has been inserted into an appropriate depth, rotating the needle 90 may be of help. If this is not effective, the stylet is replaced and the needle is advanced slightly. In some cases, withdrawing the needle incrementally will result in CSF flow when the procedure is initially unsuccessful. If spinal fluid is not obtained despite such maneuvers, the procedure should be attempted again by removing the spinal needle with the stylet in place till it arrives just under the skin and redirecting it. The needle can also be withdrawn entirely and a new needle used at a different insertion site. CSF may come very slowly in dehydrated infants when LP is performed using the lateral recumbent position.

If bony resistance is felt when the needle is not yet advanced into deep tissues, then puncture over the spinous process is likely, and the needle should be withdrawn till it is just below the skin and redirected through the interspace. If bony resistance is felt when it went deeper, then the likely cause is inadequate spinal flexion. Directing the needle more cephalad and improv-

Traumatic or unsuccessful LP a neonates is a probability in 30–50% of the time [38]. A traumatic LP may stem from improper technique. Causes include inserting the needle too far into an epidural venous plexus or through the subarachnoid space into or adjacent to the vertebral body. Nigrovic et al. found that lack of local anesthetic use and advancement of the spinal needle with the stylet in place were most prominent risk factors for a traumatic LP [39]. In the study of Glatstein et al., its incidence was independent of physician experience, sedation use or time of procedure [40]. It is also surprising for the author of these lines that the presence of a family member was not found to be associated with an increased risk of traumatic or unobtainable lumbar puncture, nor was it associated with more attempts at the procedure [41]. If blood is seen during fluid collection but the spinal needle is in proper position, the CSF often clears and the specimen does not clot. If the bloody CSF does not clear and clots form when it is collected in the test tube, then the needle should be removed and LP attempted at a different interspace with a new needle [7]. Ultrasound may minimize the number of LP attempts and decrease patient and parent anxiety by easily identifying an insertion site. It may also be useful to determine the reason for failure and the likelihood of success on continued attempts [19].

Measurement of CSF opening pressure is recommended during any LP when possible. The infant's struggling may be an obstacle for accurate measurement of opening pressure. The measurement is most reliable in a calm patient in the lateral recumbent position. As soon as the flow of CSF stabilizes and show pressure pulses with respiration, heartbeat, and jugular occlusion, the pressure manometer is immediately attached to the needle hub via a three-way stopcock. The pressure is measured at the highest level CSF reaches. Normal CSF pressure is 5–20 cm H2O in a child with neck and legs extended and 10–28 cm H2O with neck and legs flexed [7]. However, since an adult study reached totally opposite results, it is also possible that CSF pressure does not meaningfully decrease when the lower extremities are brought to extension from flexion in newborns. Kaiser et al. found the normal range of 0–7.6 cm H2O for

Getting the patient to a sitting position may increase flow in this situation.

ing the position usually overcomes this problem [7].

9.5. Traumatic LP

100 Bedside Procedures

9.6. Measurements and tests

LP is frequently associated with the minor complications of localized back pain without neurologic abnormalities, transient paresthesia during the procedure, and post-LP headache, all of which a newborn may fail to express in some way.

Permanent peripheral nerve damage is rare, because the spinal needle does not pierce the nerve, instead, it may move or stretch it [7].

Major complications after LP include LP-induced meningitis, epidural or subdural hematoma, acquired epidermoid tumor, damage to adjacent structures (disk herniation, retroperitoneal abscess, spinal cord hematoma), and cerebral herniation. Fortunately, these complications are quite rare. As previously mentioned, in the young infant, the lateral recumbent position for LP can cause respiratory obstruction, hypoxemia, and cardiovascular instability.


clinical evidence strongly suggests that these tumors can be avoided if a spinal needle with a tight fitting stylet is used [7, 48].

evidence against the presence of meningitis. In order to exclude meningitis, all three parameters should be normal; nevertheless, CSF findings may be completely normal in the very early course of neonatal meningitis. The most prudent approach would be to repeat LP after 24– 72 hours in such boderline cases: if the infant had meningitis, pleocytosis and other abnormalities consistent with meningitis would be detected in CSF obtained in this second LP [52]. Ample number of erythrocytes in CSF may be interpreted as a clue to herpes simplex virus meningitis if the physician is sure that the LP was not traumatic. Pleocytosis is more marked in bacterial and Gram-negative meningitides than in viral and Gram-positive meningitides [6].

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CSF protein concentrations higher than 100 mg/dL in term infants and 150 mg/dL in preterm neonates is consistent with bacterial meningitis and parameningeal infections, such as brain abscess, congenital infections, and intracranial hemorrhage [52]. Nigrovic et al. and Hines et al. found that CSF protein concentrations increased by approximately 1.1 and 2 mg/dL, respec-

Glucose concentrations below 30 mg/dL in term newborns and 20 mg/dL in preterm infants are consistent with bacterial meningitis. Unlike in older children, CSF glucose to serum glucose ratio is not a reliable indicator of meningitis in the first 28 days of life, because newborns often receive intravenous glucose infusions and serum glucose concentrations can rise abruptly with stress [52]. In case of a bloody tap, assessing the CSF leucocyte count by correcting it with respect to that of the peripheral blood is not recommended in that it decreases the sensitivity and provides only a slight increase in specificity. When LP is traumatic, the wisest approach is to assume the patient is having meningitis and start empirical therapy [55]. Although no statistically significant difference in LP success rate was found between the lateral and sitting positions in infants in a randomized controlled trial, we, in order to lessen the chances of dealing with a difficult LP, favor sitting position with the legs flexed for it provides the widest

Lumbar puncture of the newborn is not a smaller equivalent of the procedure performed in adults, even older children, as evidenced by its specific challenges of success and interpretation.

The author wishes to thank Ziver Öncel (83-year-old father) and Utkan Koray Öncel (7-year-

tively, for every 1000 CSF red blood cells [53, 54].

interspinous spaces and is sufficiently safe [18, 28, 56].

old son) for their joint work in preparation of figures.

No potential conflicts of interest. No financial support.

12. Conclusion

Acknowledgements

Conflict of interest

• Cerebral herniation: This is the most feared complication of LP which may lead to sudden death. Patients with an intracranial space occupying lesions, such as abscess, hematoma, and tumor are at greatest risk. Elevated intracranial pressure manifested as focal neurologic signs seems to cause herniation much more (40%) than does elevated intracranial pressure presenting with either papilledema or abnormal manometric findings alone (5 and 1.2%, respectively) [7, 49, 50]. Risk of herniation in a newborn with an open fontanel and no focal neurologic findings is much lower. In most patients, assessment of the safety of performing LP can be made based on clinical basis. Patients who have a history of focal neurologic symptoms (e.g., focal seizures, unilateral motor paralysis), focal neurologic findings on physical examination, signs of impending herniation (posturing, Glasgow Coma Score less than 8, bilateral dilated pupils, respiratory abnormalities, abnormal tone, absent Doll eye reflex), or papilledema should not undergo LP until imaging establishes that the procedure can be safely performed [7] If meningitis or other CNS infections cannot be ruled out, the patient should receive appropriate antibiotic therapy prior to the imaging study.

#### 11. Interpretation of CSF findings

Lumbar puncture is an indispensable diagnostic tool in neonatal meningitis. Direct microscopy should be performed as soon as possible, because if performed later, the erythrocytes and leukocytes likely undergo cellular lysis and escape detection. Gram- and Giemsa-stained smears of CSF should also be examined. CSF should be cultured, and if needed, sent for polymerase chain reaction. LP should ideally precede the initiation of antimicrobial therapy, but if delayed for any reason, empirical antibiotic therapy should be started immediately.

Interpretation of CSF findings is challenging in neonates, because glucose, and protein concentrations, and cell count are higher due to the high permeability of the blood-brain barrier [51] (Table 1).

Many experts accept 20–30/μL as the cutoff value for pleocytosis. Low CSF glucose, elevated CSF protein, and pleocytosis may indicate either bacterial or viral (especially herpes simplex virus) meningitis. One of these parameters being in the normal range cannot be accepted as


Table 1. Means and normal ranges of cerebrospinal parameters in neonates [51].

evidence against the presence of meningitis. In order to exclude meningitis, all three parameters should be normal; nevertheless, CSF findings may be completely normal in the very early course of neonatal meningitis. The most prudent approach would be to repeat LP after 24– 72 hours in such boderline cases: if the infant had meningitis, pleocytosis and other abnormalities consistent with meningitis would be detected in CSF obtained in this second LP [52]. Ample number of erythrocytes in CSF may be interpreted as a clue to herpes simplex virus meningitis if the physician is sure that the LP was not traumatic. Pleocytosis is more marked in bacterial and Gram-negative meningitides than in viral and Gram-positive meningitides [6].

CSF protein concentrations higher than 100 mg/dL in term infants and 150 mg/dL in preterm neonates is consistent with bacterial meningitis and parameningeal infections, such as brain abscess, congenital infections, and intracranial hemorrhage [52]. Nigrovic et al. and Hines et al. found that CSF protein concentrations increased by approximately 1.1 and 2 mg/dL, respectively, for every 1000 CSF red blood cells [53, 54].

Glucose concentrations below 30 mg/dL in term newborns and 20 mg/dL in preterm infants are consistent with bacterial meningitis. Unlike in older children, CSF glucose to serum glucose ratio is not a reliable indicator of meningitis in the first 28 days of life, because newborns often receive intravenous glucose infusions and serum glucose concentrations can rise abruptly with stress [52]. In case of a bloody tap, assessing the CSF leucocyte count by correcting it with respect to that of the peripheral blood is not recommended in that it decreases the sensitivity and provides only a slight increase in specificity. When LP is traumatic, the wisest approach is to assume the patient is having meningitis and start empirical therapy [55]. Although no statistically significant difference in LP success rate was found between the lateral and sitting positions in infants in a randomized controlled trial, we, in order to lessen the chances of dealing with a difficult LP, favor sitting position with the legs flexed for it provides the widest interspinous spaces and is sufficiently safe [18, 28, 56].

#### 12. Conclusion

clinical evidence strongly suggests that these tumors can be avoided if a spinal needle with a

• Cerebral herniation: This is the most feared complication of LP which may lead to sudden death. Patients with an intracranial space occupying lesions, such as abscess, hematoma, and tumor are at greatest risk. Elevated intracranial pressure manifested as focal neurologic signs seems to cause herniation much more (40%) than does elevated intracranial pressure presenting with either papilledema or abnormal manometric findings alone (5 and 1.2%, respectively) [7, 49, 50]. Risk of herniation in a newborn with an open fontanel and no focal neurologic findings is much lower. In most patients, assessment of the safety of performing LP can be made based on clinical basis. Patients who have a history of focal neurologic symptoms (e.g., focal seizures, unilateral motor paralysis), focal neurologic findings on physical examination, signs of impending herniation (posturing, Glasgow Coma Score less than 8, bilateral dilated pupils, respiratory abnormalities, abnormal tone, absent Doll eye reflex), or papilledema should not undergo LP until imaging establishes that the procedure can be safely performed [7] If meningitis or other CNS infections cannot be ruled out, the

patient should receive appropriate antibiotic therapy prior to the imaging study.

Lumbar puncture is an indispensable diagnostic tool in neonatal meningitis. Direct microscopy should be performed as soon as possible, because if performed later, the erythrocytes and leukocytes likely undergo cellular lysis and escape detection. Gram- and Giemsa-stained smears of CSF should also be examined. CSF should be cultured, and if needed, sent for polymerase chain reaction. LP should ideally precede the initiation of antimicrobial therapy, but if delayed

Interpretation of CSF findings is challenging in neonates, because glucose, and protein concentrations, and cell count are higher due to the high permeability of the blood-brain barrier [51]

Many experts accept 20–30/μL as the cutoff value for pleocytosis. Low CSF glucose, elevated CSF protein, and pleocytosis may indicate either bacterial or viral (especially herpes simplex virus) meningitis. One of these parameters being in the normal range cannot be accepted as

Age Erythrocytes (μL/L) Leukocytes (μL/L) Protein (mg/dL) Glucose (mg/dL)

Preterm— < 7 d 30 (0–333) 9 (0–30) 100 (50–290) (mostly <200) 54 (27–99) Preterm— > 7 d 30 12 (2–70) 90 (50–260) (mostly <150) 54 (27–99) Term— < 7 d 9 (0–50) 5 (0–21) 60 (30–250) 54 (27–99) Term— > 7 d <10 3 (0–10) 50 (20–80) 54 (27–99)

for any reason, empirical antibiotic therapy should be started immediately.

Table 1. Means and normal ranges of cerebrospinal parameters in neonates [51].

tight fitting stylet is used [7, 48].

102 Bedside Procedures

11. Interpretation of CSF findings

(Table 1).

d: day(s).

Lumbar puncture of the newborn is not a smaller equivalent of the procedure performed in adults, even older children, as evidenced by its specific challenges of success and interpretation.

## Acknowledgements

The author wishes to thank Ziver Öncel (83-year-old father) and Utkan Koray Öncel (7-yearold son) for their joint work in preparation of figures.

#### Conflict of interest

No potential conflicts of interest. No financial support.

## Author contribution

The author contributed as the only person to this chapter with conception and design of the manuscript, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.

[7] Cronan KM, Wiley II JF. Lumbar puncture. In: King C, Henretig FM, editors. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wil-

Lumbar Puncture of the Newborn

105

http://dx.doi.org/10.5772/intechopen.70498

[8] Fastle RK, Bothner J. Lumbar puncture: Indications, contraindications, technique, and complications in children. In: Post T, editor. UpToDate. Waltham, MA: UpToDate; 2017.

[9] Howard SC, Gajjar A, Ribeiro RC, Rivera GK, Rubnitz JE, Sandlund JT, et al. Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. Journal of the American Medical Association. 2000;284:2222-2224. DOI: jbr00199 [pii] [10] Kneen R, Michael BD, Menson E, Mehta B, Easton A, Hemingway C, et al. Management of suspected viral encephalitis in children. Association of British Neurologists and British Paediatric Allergy, Immunology and Infection Group National Guidelines. Journal of

[11] Silverman R, Kwiatkowski T, Bernstein S, Sanders N, Hilgartner M, Cahill-Bordas M, et al. Safety of lumbar puncture in patients with hemophilia. Annals of Emergency

[12] Narchi H, Ghatasheh G, Hassani NA, Reyami LA, Khan Q. Why do some parents refuse consent for lumbar puncture on their child? A qualitative study. Hospital Pediatrics.

[13] Narchi H, Ghatasheh G, Hassani NA, Reyami LA, Khan Q. Comparison of underlying factors behind parental refusal or consent for lumbar puncture. World Journal of Pediat-

[14] Uysalol M, İncioğlu A, Taşdemir M, Pasli E, Olgun T. Parents' attitude and doubts about lumbar puncture. The Medical Bulletin of Sisli Etfal Hospital. 2007;41:23-27. ISSN: 1302-

[15] Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, et al. Practice guidelines for the management of bacterial meningitis. Clinical Infectious Diseases.

[16] Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. New England Journal of

[17] Spellberg B. Is computed tomography of the head useful before lumbar puncture? Clini-

[18] Hanson AL, Ros S, Soprano J. Analysis of infant lumbar puncture success rates: Sitting flexed versus lateral flexed positions. Pediatric Emergency Care. 2014;30:311-314. DOI:

[19] Kim S, Adler DK. Ultrasound-assisted lumbar puncture in pediatric emergency medicine. Journal of Emergency Medicine. 2014;47:59-64. DOI: 10.1016/j.jemermed.2012.09.149

kins; 2008. pp. 505-514. ISBN/ISSN: 9780781753869

Infection. 2012;64:449-477. DOI: 10.1016/j.jinf.2011.11.013

Medicine. 1993;22:1739-1742. ISSN: 0196-0644

2012;2:93-98. DOI: 10.1542/hpeds.2011-0034

2004;39:1267-1284. DOI: 10.1086/425368

10.1097/PEC.0000000000000119

7123

rics. 2013;9:336-341. DOI: 10.1007/s12519-013-0419-z

Medicine. 2001;345:1727-1733. DOI: 10.1056/NEJMoa010399

cal Infectious Diseases. 2005;40:1061. DOI: 10.1086/428668

[Accessed: June 23, 2017]

## Supportive foundations

None.

## Author details

Selim Öncel

Address all correspondence to: selimoncel@doctor.com

Division of Pediatric Infectious Diseases, Department of Pediatrics and Child Health, Section of Internal Medical Sciences, Kocaeli University Faculty of Medicine, Kocaeli, Turkey

## References


[7] Cronan KM, Wiley II JF. Lumbar puncture. In: King C, Henretig FM, editors. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. pp. 505-514. ISBN/ISSN: 9780781753869

Author contribution

104 Bedside Procedures

approval of the final version.

Supportive foundations

Address all correspondence to: selimoncel@doctor.com

Springer; 2015. pp. 3-16. DOI: 10.1007/978-3-319-01225-4

None.

Author details

Selim Öncel

References

sciences. 1997;6:147-153

ISBN: 13: 978-1-4441-6494-7

10.1136/adc.2005.087551

978-0323241472

The author contributed as the only person to this chapter with conception and design of the manuscript, literature review and analysis, drafting and critical revision and editing, and final

Division of Pediatric Infectious Diseases, Department of Pediatrics and Child Health, Section

[1] Deisenhammer F. The history of cerebrospinal fluid. In: Deisenhammer F, Sellebjerg F, Teunissen CE, Tumani H, editors. Cerebrospinal Fluid in Clinical Neurology. Heidelberg:

[2] Frederiks JA, Koehler PJ. The first lumbar puncture. Journal of the History of the Neuro-

[3] Moore DP, Puri BK. In: Moore DP, Puri BK, editors. Textbook of Clinical Neuropsychiatry and Behavioral Neuroscience. 3rd ed. Boca Raton, FL: CRC Press; 2012. pp. 332-334.

[4] Flidel-Rimon O, Leibovitz E, Eventov Friedman S, Juster-Reicher A, Shinwell ES. Is lumbar puncture (LP) required in every workup for suspected late-onset sepsis in neo-

[5] Malbon K, Mohan R, Nicholl R. Should a neonate with possible late onset infection always have a lumbar puncture? Archives of Disease in Childhood. 2006;91:75-76. DOI:

[6] Nizet V, Klein JO. Bacterial sepsis and meningitis. In: Wilson CB, Nizet V, Maldonado YA, Remington JS, Klein JO, editors. Remington and Klein's Infectious Diseases of the Fetus and Newborn Infant. 8th ed. Philadelphia, PA: Elsevier Saunders; 2016. pp. 217-271. DOI:

nates? Acta Paediatrica. 2011;100:303-304. DOI: 10.1111/j.1651-2227.2010.02012.x

of Internal Medical Sciences, Kocaeli University Faculty of Medicine, Kocaeli, Turkey


[20] Tumani H. Physiology and constituents of CSF. In: Cerebrospinal Fluid in Clinical Neurology. Heidelberg: Springer; 2015. pp. 25-34. DOI: 10.1007/978-3-319-01225-4

[33] Bilić E, Bilić E, Dadić M, Boban M. Calculating lumbar puncture depth in children.

Lumbar Puncture of the Newborn

107

http://dx.doi.org/10.5772/intechopen.70498

[34] Craig F, Stroobant J, Winrow A, Davies H. Depth of insertion of a lumbar puncture

[35] Shenkman Z, Rathaus V, Jedeikin R, Konen O, Hoppenstein D, Snyder M, et al. The distance from the skin to the subarachnoid space can be predicted in premature and formerpremature infants. Canadian Journal of Anesthesia. 2004;51:160-162. DOI: 10.1007/

[36] Arthurs OJ, Murray M, Zubier M, Tooley J, Kelsall W. Ultrasonographic determination of neonatal spinal canal depth. Archives of Disease in Childhood-Fetal and Neonatal Edi-

[37] Oulego-Erroz I, Mora-Matilla M, Alonso-Quintela P, Rodríguez-Blanco S, Mata-Zubillaga D, de Armentia SLL. Ultrasound evaluation of lumbar spine anatomy in newborn infants: İmplications for optimal performance of lumbar puncture. Journal of Pedi-

[38] Muthusami P, Robinson AJ, Shroff MM. Ultrasound guidance for difficult lumbar puncture in children: Pearls and pitfalls. Pediatric Radiology. 2017;47:822-830. DOI: 10.1007/

[39] Nigrovic LE, Kuppermann N, Neuman MI. Risk factors for traumatic or unsuccessful lumbar punctures in children. Annals of Emergency Medicine. 2007;49:762-771. DOI:

[40] Glatstein MM, Zucker-Toledano M, Arik A, Scolnik D, Oren A, Reif S. Incidence of traumatic lumbar puncture: Experience of a large, tertiary care pediatric hospital. Clinical

[41] Nigrovic LE, McQueen AA, Neuman MI. Lumbar puncture success rate is not influenced by family-member presence. Pediatrics. 2007;120:e777-e782. DOI: 10.1542/peds.2006-3442

[42] Kaiser A, Whitelaw AG. Normal cerebrospinal fluid pressure in the newborn. Neuropediatrics.

[43] Ellis RW, Strauss LC, Wiley JM, Killmond TM, Ellis RW. A simple method of estimating cerebrospinal fluid pressure during lumbar puncture. Pediatrics. 1992;89:895-897. ISSN:

[44] Teele DW, Dashefsky B, Rakusan T, Klein JO. Meningitis after lumbar puncture in children with bacteremia. New England Journal of Medicine. 1981;305:1079-1081. DOI:

[45] Shapiro ED, Aaron NH, Wald ER, Chiponis D. Risk factors for development of bacterial meningitis among children with occult bacteremia. Journal of Pediatrics. 1986;109:15-19.

Pediatrics (Philadelphia). 2011;50:1005-1009. DOI: 10.1177/0009922811410309

Collegium Antropologicum. 2003;27:623-626. ISSN: 0350-6134

tion. 2008;93:F451-F454. DOI: 10.1136/adc.2007.129221

atrics. 2014;165:862-865.e1. DOI: 10.1016/j.jpeds.2014.06.038

BF03018776

s00247-017-3794-0

0031-4005

ISSN: 0022-3476

10.1016/j.annemergmed.2006.10.018

1986;17:100-102. DOI: 10.1055/s-2008-1052509

10.1056/NEJM198110293051810

needle. Archives of Disease in Childhood. 1997;77:450. ISSN: 1468-2044


[33] Bilić E, Bilić E, Dadić M, Boban M. Calculating lumbar puncture depth in children. Collegium Antropologicum. 2003;27:623-626. ISSN: 0350-6134

[20] Tumani H. Physiology and constituents of CSF. In: Cerebrospinal Fluid in Clinical Neurology. Heidelberg: Springer; 2015. pp. 25-34. DOI: 10.1007/978-3-319-01225-4

[21] Ferner H, Staubesand J, editors. Sobotta Atlas of Human Anatomy. 10th Engl. ed. Munich:

[22] Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB. A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics.

[23] Kaur G, Gupta P, Kumar A. A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns. Archives of Pediatrics and Adolescent Medicine.

[24] Cadigan BA, Cydulka RK, Werner SL, Jones RA. Evaluating infant positioning for lumbar puncture using sonographic measurements. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine. 2011;18:215-218. DOI: 10.1111/

[25] Lo MD, Parisi MT, Brown JC, Klein EJ. Sitting or tilt position for infant lumbar puncture does not increase ultrasound measurements of lumbar subarachnoid space width. Pediatric Emergency Care. 2013;29:588-591. DOI: 10.1097/PEC.0b013e31828e

[26] Fisher A, Lupu L, Gurevitz B, Brill S, Margolin E, Hertzanu Y. Hip flexion and lumbar puncture: A radiological study. Anaesthesia. 2001;56:262-266. ISSN: 0003-2409

[27] Sandoval M, Shestak W, Stürmann K, Hsu C. Optimal patient position for lumbar puncture, measured by ultrasonography. Emergency Radiology. 2004;10:179-181. DOI:

[28] Öncel S, Günlemez A, Anik Y, Alvur M. Positioning of infants in the neonatal intensive care unit for lumbar puncture as determined by bedside ultrasonography. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2013;98:F133-F135. DOI: 10.1136/

[29] Baxter AL, Welch JC, Burke BL, Isaacman DJ. Pain, position, and stylet styles: İnfant lumbar puncture practices of pediatric emergency attending physicians. Pediatric Emer-

[30] Gleason CA, Martin RJ, Anderson J V, Carlo WA, Sanniti KJ, Fanaroff AA. Optimal position for a spinal tap in preterm infants. Pediatrics. 1983;71:31-35. ISSN: 0031-4005 [31] Pinheiro JM, Furdon S, Ochoa LF. Role of local anesthesia during lumbar puncture in

[32] Bruccoleri RE, Chen L. Needle-entry angle for lumbar puncture in children as determined by using ultrasonography. Pediatrics. 2011;127:e921-e926. DOI: 10.1542/peds.2010-2511

Urban & Schwarzenberg; 1982. p. 88. ISBN: 3-541-72710-1

2003;157:1065-1070. DOI: 10.1001/archpedi.157.11.1065

2002;109:1093-1099. ISSN: 1098-4275

j.1553-2712.2010.00977.x

10.1007/s10140-003-0286-3

archdischild-2011-301475

gency Care. 2004;20:816-820. ISSN: 1535-1815

neonates. Pediatrics. 1993;91:379-382. ISSN: 0031-4005

630d

106 Bedside Procedures


[46] Eng RH, Seligman SJ. Lumbar puncture-induced meningitis. Journal of the American Medical Association. 1981;245:1456-1459. ISSN: 0098-7484

**Chapter 6**

**Provisional chapter**

**Bedside Percutaneous Cholecystostomy**

**Bedside Percutaneous Cholecystostomy**

DOI: 10.5772/intechopen.70500

Although percutaneous cholecystostomy historically is an alternative to cholecystectomy, it is typically performed as a bridge to gallbladder removal. As a low mortality procedure, it proves itself a valuable tool in morbid patients such as the elderly and the critically ill who present with acute cholecystitis and as an alternate route for biliary access. In high-risk patients, PC can be performed at the patient's bedside in patients who are too unstable to be transported outside the ICU. PC is performed using ultrasound, CT, or fluoroscopic guidance; however, bedside PC can only be performed using ultrasound. Ultrasound is readily available and portable and allows for real-time imaging. A 2010 study performed by Donkol et al. demonstrated success rates for CT (93%), US (46%), and fluoroscopy (62%). Though US had the lowest success rate, it remains the only option for those critically ill who cannot tolerate transportation or an immediate cholecystectomy. Contraindications of PC include hemorrhage, pericholecystic abscess, gallbladder tumor, etc. Complications include bile leak, hemorrhage, sepsis, bowel perforation, etc. The gallbladder is a small organ with much pathology. Having the knowledge and skill to adequately perform this procedure is essential, especially in

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Acute cholecystitis is a serious condition, which requires rapid treatment. The gold standard treatment for acute cholecystitis is surgical cholecystectomy [1–3]. In modern practice, this is most commonly performed via a laparoscopic approach [3]. Surgical resection, whether open or laparoscopic, requires general anesthesia, and therefore a certain level of patient

Michelle Maneevese, Rahul Sheth,

http://dx.doi.org/10.5772/intechopen.70500

**Abstract**

**1. Introduction**

Syed Aziz-Ur Rahman and Joshua Kuban

Michelle Maneevese, Rahul Sheth, Syed Aziz-Ur Rahman and Joshua Kuban

Additional information is available at the end of the chapter

patients with septic shock in need of source control.

**Keywords:** cholecystostomy, percutaneous, cholecystitis, biliary, gallbladder

Additional information is available at the end of the chapter


## **Chapter 6**

**Provisional chapter**

## **Bedside Percutaneous Cholecystostomy**

**Bedside Percutaneous Cholecystostomy**

Michelle Maneevese, Rahul Sheth, Syed Aziz-Ur Rahman and Joshua Kuban Aziz-Ur Rahman and Joshua Kuban Additional information is available at the end of the chapter

Michelle Maneevese, Rahul Sheth, Syed

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70500

#### **Abstract**

[46] Eng RH, Seligman SJ. Lumbar puncture-induced meningitis. Journal of the American

[47] Edelson RN, Chernik NL, Posner JB. Spinal subdural hematomas complicating lumbar

[48] Batnitzky S, Keucher TR, Mealey J, Campbell RL. Iatrogenic intraspinal epidermoid tumors. Journal of the American Medical Association. 1977;237:148-150. ISSN: 0098-7484

[49] Duffy GP. Lumbar puncture in the presence of raised intracranial pressure. British Med-

[50] Korein J, Cravioto H, Leicach M. Reevaluation of lumbar puncture; a study of 129 patients with papilledema or intracranial hypertension. Neurology. 1959;9:290-297. ISSN:

[51] Kapetanakis, A, Hagmann, C, Rennie, J. The baby with a suspected infection. In: Rennie J, Hagmann C, Robertson N, editors. Neonatal Cerebral Investigation. Cambridge: Cam-

[52] Edwards MS, Baker CJ. Bacterial meningitis in the neonate: Clinical features and diagnosis. In: Post TW, editor. UpToDate. Waltham, MA: UpToDate; 2017. [Accessed: June 23, 2017]

[53] Nigrovic LE, Shah SS, Neuman MI. Correction of cerebrospinal fluid protein for the presence of red blood cells in children with a traumatic lumbar puncture. Journal of

[54] Hines EM, Nigrovic LE, Neuman MI, Shah SS. Adjustment of cerebrospinal fluid protein for red blood cells in neonates and young infants. Journal of Hospital Medicine.

[55] Greenberg RG, Smith PB, Cotten CM, Moody MA, Clark RH, Benjamin DK, Jr. Traumatic lumbar punctures in neonates: Test performance of the cerebrospinal fluid white blood cell count. Pediatric Infectious Disease Journal. 2008;27:1047-1051. DOI: 10.1097/

[56] Hanson AL, Schunk JE, Corneli HM, Soprano JV. A randomized controlled trial of positioning for lumbar puncture in young infants. Pediatric Emergency Care. 2016;32:504-507.

Pediatrics. 2011;159:158-159. DOI: 10.1016/j.jpeds.2011.02.038

bridge University Press; 2008. pp. 269-280. DOI: 10.1017/CBO9780511544750.015

Medical Association. 1981;245:1456-1459. ISSN: 0098-7484

ical Journal. 1969;1:407-409. ISSN: 0007-1447

2012;7:325-328. DOI: 10.1002/jhm.1920

DOI: 10.1097/PEC.0000000000000469

INF.0b013e31817e519b

0028-3878

108 Bedside Procedures

puncture. Archives of Neurology. 1974;31:134-137. ISSN: 0003-9942

Although percutaneous cholecystostomy historically is an alternative to cholecystectomy, it is typically performed as a bridge to gallbladder removal. As a low mortality procedure, it proves itself a valuable tool in morbid patients such as the elderly and the critically ill who present with acute cholecystitis and as an alternate route for biliary access. In high-risk patients, PC can be performed at the patient's bedside in patients who are too unstable to be transported outside the ICU. PC is performed using ultrasound, CT, or fluoroscopic guidance; however, bedside PC can only be performed using ultrasound. Ultrasound is readily available and portable and allows for real-time imaging. A 2010 study performed by Donkol et al. demonstrated success rates for CT (93%), US (46%), and fluoroscopy (62%). Though US had the lowest success rate, it remains the only option for those critically ill who cannot tolerate transportation or an immediate cholecystectomy. Contraindications of PC include hemorrhage, pericholecystic abscess, gallbladder tumor, etc. Complications include bile leak, hemorrhage, sepsis, bowel perforation, etc. The gallbladder is a small organ with much pathology. Having the knowledge and skill to adequately perform this procedure is essential, especially in patients with septic shock in need of source control.

DOI: 10.5772/intechopen.70500

**Keywords:** cholecystostomy, percutaneous, cholecystitis, biliary, gallbladder

#### **1. Introduction**

Acute cholecystitis is a serious condition, which requires rapid treatment. The gold standard treatment for acute cholecystitis is surgical cholecystectomy [1–3]. In modern practice, this is most commonly performed via a laparoscopic approach [3]. Surgical resection, whether open or laparoscopic, requires general anesthesia, and therefore a certain level of patient

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

stability. In patients who are not operative candidates, percutaneous cholecystostomy (PC) is an alternative approach.

not be possible to access the gallbladder percutaneously due to intervening bowel or because

Bedside Percutaneous Cholecystostomy http://dx.doi.org/10.5772/intechopen.70500 111

In addition to calculous cholecystitis, percutaneous cholecystostomy is also indicated for acalculous cholecystitis, seen often in patients in intensive care, and pregnant women where medical treatment alone is unsuccessful [7]. Acute acalculous cholecystitis is associated with a high morbidity and mortality and is thought to be a manifestation of systemic disease rather than a process confined to the gallbladder alone [8]. Because it can be difficult to recognize clinical signs of acute acalculous cholecystitis and intensive care patients are often on antibiotics and pain medication as well as parenteral nutrition (increasing their risk), percutaneous cholecystostomy can be used as diagnostic and therapeutic procedure in patients with unexplained sepsis [9]. For some, PC may be a definitive treatment for

In elderly patients with multiple comorbidities or poor general condition, percutaneous cholecystostomy can be performed safely and after removal a cholecystectomy can be performed

In pregnant patients, acute cholecystitis is seen with lower frequency, 0.1%. The traditional management during pregnancy is conservative treatment; however, this may lead to prolonged treatment and more complications. Laparoscopic cholecystectomy is also available, though risks with anesthesia and surgery still provide significant drawbacks. For those patients with failure to respond to conservative management, percutaneous cholecystostomy is used as a temporizing measure, until the patient is able to have abdominal surgery post

Prior to the procedure, confirm diagnosis by obtaining history and performing physical exam. All imaging available should be reviewed to confirm indication for the procedure. Cross sectional imaging should be obtained prior to bedside placement, except in emergent cases, to assess gallbladder anatomy and plan safe route to the gallbladder. Review all prior procedure

Blood count, liver panel and coagulation profile need to be obtained and reviewed. Usually, septic patients are on broad-spectrum antibiotics. If not, broad-spectrum IV antibiotics should be given 1–4 h prior to the procedure. Some examples of acceptable antibiotics include levofloxacin 1 g, Unasyn (ampicillin plus sulbactam) 3 g IV, and ertapenum 1 g IV [11]. Analgesia and sedation should be arranged according to patient comfort and institution

Obtain informed consent outline the risk and benefits of the procedure. A "time out" should

be performed to ensure the correct patient, procedure, and location [11].

of gallbladder rupture and decompression.

acalculous cholecystitis [1, 10].

partum [10].

notes if available.

protocols [11].

with acceptable conversion rate [10].

**4. Pre-procedural evaluation**

Percutaneous cholecystostomy is a minimally invasive, image-guided intervention. The goal of PC is to quickly decompress the gallbladder to prevent gallbladder rupture and resultant peritonitis, as well as to provide infection source control. When combined with antibiotics, this is an effective way to give the body time to lessen the inflammatory response in preparation for surgery. In patients with acalculous cholecystitis, PC can obviate the need for surgery [1, 2]. Furthermore, it makes possible the ability to perform diagnostic cholangiography and access for intervention to eliminate common bile duct stones [4]. Options for image guidance include ultrasound, computed tomography, and fluoroscopy. When performed at the bedside, this procedure is done with ultrasound guidance and has the advantage of avoiding the need to transfer patients to the operating room or Interventional Radiology suite [1, 2, 6].

#### **2. History**

The first open cholecystostomy was performed in 1684 followed by the first open cholecystectomy in 1878 [5]. A diagnostic test in 1921 placed dye in the gallbladder by way of a cholecystostomy tube. Percutaneous cholecystostomy was first described by Radder as an alternative to immediate open or laparoscopic cholecystectomy on the basis that initial drainage of the gallbladder will result in decompression of the biliary system and subsequent resolution of gallbladder inflammation [4]. He then performed the first percutaneous cholecystostomy (PC) using ultrasound guidance in 1979 for empyema of the gallbladder [6]. Other imaging modalities including CT and fluoroscopic guidance were used starting in 1985 [17].

## **3. Indications**

Acute cholecystitis is a clinical diagnosis based on history, physical exam, laboratory values and imaging. The most common cause of acute cholecystitis is cystic duct obstruction from biliary stones (calculous cholecystitis) [3]. Once the diagnosis of acute calculous cholecystitis is made, a surgical evaluation is warranted. The majority of patient will go on to surgical resection of the gallbladder. For patients with acute cholecystitis who are not surgical candidates, percutaneous cholecystostomy is indicated. The majority of PC's placed are done in the IR suite or Radiology procedure room with CT or US and Fluoroscopy image guidance [7]. Bedside cholecystostomy is indicated in patients who are too unstable to travel to IR suite for tube placement [7, 19].

There are no absolute contraindications to emergent PC placement if the procedure is lifesaving. Relative contraindications include uncorrectable coagulopathy. In some cases it may not be possible to access the gallbladder percutaneously due to intervening bowel or because of gallbladder rupture and decompression.

In addition to calculous cholecystitis, percutaneous cholecystostomy is also indicated for acalculous cholecystitis, seen often in patients in intensive care, and pregnant women where medical treatment alone is unsuccessful [7]. Acute acalculous cholecystitis is associated with a high morbidity and mortality and is thought to be a manifestation of systemic disease rather than a process confined to the gallbladder alone [8]. Because it can be difficult to recognize clinical signs of acute acalculous cholecystitis and intensive care patients are often on antibiotics and pain medication as well as parenteral nutrition (increasing their risk), percutaneous cholecystostomy can be used as diagnostic and therapeutic procedure in patients with unexplained sepsis [9]. For some, PC may be a definitive treatment for acalculous cholecystitis [1, 10].

In elderly patients with multiple comorbidities or poor general condition, percutaneous cholecystostomy can be performed safely and after removal a cholecystectomy can be performed with acceptable conversion rate [10].

In pregnant patients, acute cholecystitis is seen with lower frequency, 0.1%. The traditional management during pregnancy is conservative treatment; however, this may lead to prolonged treatment and more complications. Laparoscopic cholecystectomy is also available, though risks with anesthesia and surgery still provide significant drawbacks. For those patients with failure to respond to conservative management, percutaneous cholecystostomy is used as a temporizing measure, until the patient is able to have abdominal surgery post partum [10].

## **4. Pre-procedural evaluation**

stability. In patients who are not operative candidates, percutaneous cholecystostomy (PC)

Percutaneous cholecystostomy is a minimally invasive, image-guided intervention. The goal of PC is to quickly decompress the gallbladder to prevent gallbladder rupture and resultant peritonitis, as well as to provide infection source control. When combined with antibiotics, this is an effective way to give the body time to lessen the inflammatory response in preparation for surgery. In patients with acalculous cholecystitis, PC can obviate the need for surgery [1, 2]. Furthermore, it makes possible the ability to perform diagnostic cholangiography and access for intervention to eliminate common bile duct stones [4]. Options for image guidance include ultrasound, computed tomography, and fluoroscopy. When performed at the bedside, this procedure is done with ultrasound guidance and has the advantage of avoiding the need to transfer patients to the operating room or Interventional Radiology

The first open cholecystostomy was performed in 1684 followed by the first open cholecystectomy in 1878 [5]. A diagnostic test in 1921 placed dye in the gallbladder by way of a cholecystostomy tube. Percutaneous cholecystostomy was first described by Radder as an alternative to immediate open or laparoscopic cholecystectomy on the basis that initial drainage of the gallbladder will result in decompression of the biliary system and subsequent resolution of gallbladder inflammation [4]. He then performed the first percutaneous cholecystostomy (PC) using ultrasound guidance in 1979 for empyema of the gallbladder [6]. Other imaging modalities including CT and fluoroscopic guidance were used starting

Acute cholecystitis is a clinical diagnosis based on history, physical exam, laboratory values and imaging. The most common cause of acute cholecystitis is cystic duct obstruction from biliary stones (calculous cholecystitis) [3]. Once the diagnosis of acute calculous cholecystitis is made, a surgical evaluation is warranted. The majority of patient will go on to surgical resection of the gallbladder. For patients with acute cholecystitis who are not surgical candidates, percutaneous cholecystostomy is indicated. The majority of PC's placed are done in the IR suite or Radiology procedure room with CT or US and Fluoroscopy image guidance [7]. Bedside cholecystostomy is indicated in patients who are too unstable to travel to IR suite for

There are no absolute contraindications to emergent PC placement if the procedure is lifesaving. Relative contraindications include uncorrectable coagulopathy. In some cases it may

is an alternative approach.

110 Bedside Procedures

suite [1, 2, 6].

**2. History**

in 1985 [17].

**3. Indications**

tube placement [7, 19].

Prior to the procedure, confirm diagnosis by obtaining history and performing physical exam. All imaging available should be reviewed to confirm indication for the procedure. Cross sectional imaging should be obtained prior to bedside placement, except in emergent cases, to assess gallbladder anatomy and plan safe route to the gallbladder. Review all prior procedure notes if available.

Blood count, liver panel and coagulation profile need to be obtained and reviewed. Usually, septic patients are on broad-spectrum antibiotics. If not, broad-spectrum IV antibiotics should be given 1–4 h prior to the procedure. Some examples of acceptable antibiotics include levofloxacin 1 g, Unasyn (ampicillin plus sulbactam) 3 g IV, and ertapenum 1 g IV [11]. Analgesia and sedation should be arranged according to patient comfort and institution protocols [11].

Obtain informed consent outline the risk and benefits of the procedure. A "time out" should be performed to ensure the correct patient, procedure, and location [11].

## **5. Techniques**

Percutaneous cholecystostomy may be performed using ultrasound, CT, or fluoroscopic guidance. Fluoroscopy and computed tomography generally have limited availability, increased expense, exposure to radiation, and perhaps the limiting factor, the need to transfer critically ill patients to the radiology suite. A 2010 study performed by Donkol et al. demonstrated success rates for CT (93%), US (46%), and fluoroscopy (62%). Though US had the lowest success rate, it remains the only option for those critically ill who cannot tolerate transportation outside the intensive care unit or an immediate cholecystectomy. Also, at most experienced centers that rate of procedural success with ultrasound guidance is far higher than 46%.

The patient is positioned supine with arm abducted to an arm board. Using a convex probe at frequency range 2.5–6 MHz, the gallbladder is evaluated for the best approach. Confirm liver anatomy is as expected [1, 2, 11].

the catheter. This is locked into place by various mechanisms, depending on catheter manufacturer. Straight drains should be avoided, as the pigtail mechanism will help to prevent tube malposition or withdrawal. The catheter should then be aspirated to ensure bilious return. The catheter course should also be imaged with ultrasound to confirm intraluminal location of all of the sideholes. The advantage to the Seldinger technique is the use of a small needle for initial access, reducing risk of damage to surrounding structures and bleeding if the initial attempt is not successful. The biggest disadvantage to this technique is that through the multiple exchanges there is mixing of infected bilious material from the gallbladder and blood from the transhepatic tract, potentially increasing the risk for sepsis. In the case of the transperitoneal approach, this technique would allow for spillage of bilious material into the peritoneum and increase the risk of peritonitis. Furthermore, this technique requires multiple steps from initial puncture to cath-

Bedside Percutaneous Cholecystostomy http://dx.doi.org/10.5772/intechopen.70500 113

**Figure 1.** Ultrasound guided Seldinger technique with needle in the gallbladder lumen.

eter placement, making it more time consuming than the trocar technique [1, 2, 12, 19].

The second technique is the trocar technique, in which a stiff trocar needle is inserted though the drain as the inner stiffener, and they are advanced as a unit in a single pass into the gallbladder lumen under ultrasound guidance. While eliminating steps in the procedure compared with the Seldinger technique, there is a high risk of bleeding if the initial pass is not successful, as this would require multiple 8–12 F holes in the liver capsule. Damage to adjacent structures, if this does occur, would be more severe than with the Seldinger technique [1, 2, 12, 19].

After access is gained into the gallbladder (confirmed by aspiration of bile), bile is withdrawn

Technical failure can be seen with porcelain gallbladder, thickened gallbladder wall, or small gallbladder lumen (from stones or one that is too small to accommodate a pigtail catheter) [9].

Procedure-associated morbidity can be extremely high in a critically ill patient population [14]. Although this is the best alternative to preventing/treating biliary sepsis aside from surgery,

The drainage catheter is fixed to the skin with suture and a sterile dressing is applied.

for culture and the drain is connected to gravity drainage.

**6. Post-procedural care**

In the transhepatic approach, the catheter is to pass via the bare area of the liver in order to access the gallbladder. This may be done subcostally, thought the intercostal approach is preferred to minimize tube dislodgement and kinking. When using an intercostal approach, care must be taken to avoid puncturing the diaphragm, pleura or the intercostal neurovascular bundle as it passes inferior to the rib. The transhepatic approach decreases the risk of bile leaks and colon injury, which are more common in the transperitoneal approach [1, 2, 12, 19]. Higher rates of bleeding are associated with the transhepatic approach [13].

The transperitoneal approach is a direct puncture of the gallbladder, often used in patients who have coagulopathies, which preclude the transhepatic approach. The gallbladder must be distended and in close proximity to the abdominal wall [1, 2, 12, 19]. In the author's opinion, the transhepatic, intercostal approach is the safest and preferred method.

Once a trajectory has been planned, the patient is then sterilely prepped and draped in a supine position with right arm abducted [11]. The entry site is anesthetized with 1–2% buffered lidocaine.

There are two techniques used for placement of the pigtail catheter into the gallbladder—the modified Seldinger technique, and the trocar technique.

The modified Seldinger technique consists of inserting a needle into the gallbladder under direct US guidance (**Figure 1**). The most common needle is an 18 G 10 cm hollow core needle, although smaller gauge needles can be used with 0.018 inch access systems. Aspiration of the needle should confirm bilious return. A 0.035 inch guidewire is then inserted through the needle into the gallbladder lumen. The wire should be seen looping in the gallbladder lumen with ultrasound. Use a scalpel to create a skin nick at the needle entry site and bluntly dilate this with a Kelly clamp or curved snap. The needle is removed and dilators of increasing diameters are advanced over the wire just into the gallbladder in order to dilate a tract large enough to accommodate a drain. The most common drain sizes are 8, 10 and 12 F, with larger sizes chosen for more viscous fluid. The catheter is advanced over the wire under ultrasound guidance. Once the tip enters the gallbladder, the catheter is unlocked from the inner stiffener and further advanced over the wire. The wire and stiffener are then removed, and pulling on the drain string forms

**Figure 1.** Ultrasound guided Seldinger technique with needle in the gallbladder lumen.

the catheter. This is locked into place by various mechanisms, depending on catheter manufacturer. Straight drains should be avoided, as the pigtail mechanism will help to prevent tube malposition or withdrawal. The catheter should then be aspirated to ensure bilious return. The catheter course should also be imaged with ultrasound to confirm intraluminal location of all of the sideholes. The advantage to the Seldinger technique is the use of a small needle for initial access, reducing risk of damage to surrounding structures and bleeding if the initial attempt is not successful. The biggest disadvantage to this technique is that through the multiple exchanges there is mixing of infected bilious material from the gallbladder and blood from the transhepatic tract, potentially increasing the risk for sepsis. In the case of the transperitoneal approach, this technique would allow for spillage of bilious material into the peritoneum and increase the risk of peritonitis. Furthermore, this technique requires multiple steps from initial puncture to catheter placement, making it more time consuming than the trocar technique [1, 2, 12, 19].

The second technique is the trocar technique, in which a stiff trocar needle is inserted though the drain as the inner stiffener, and they are advanced as a unit in a single pass into the gallbladder lumen under ultrasound guidance. While eliminating steps in the procedure compared with the Seldinger technique, there is a high risk of bleeding if the initial pass is not successful, as this would require multiple 8–12 F holes in the liver capsule. Damage to adjacent structures, if this does occur, would be more severe than with the Seldinger technique [1, 2, 12, 19].

After access is gained into the gallbladder (confirmed by aspiration of bile), bile is withdrawn for culture and the drain is connected to gravity drainage.

The drainage catheter is fixed to the skin with suture and a sterile dressing is applied.

Technical failure can be seen with porcelain gallbladder, thickened gallbladder wall, or small gallbladder lumen (from stones or one that is too small to accommodate a pigtail catheter) [9].

## **6. Post-procedural care**

**5. Techniques**

112 Bedside Procedures

anatomy is as expected [1, 2, 11].

Percutaneous cholecystostomy may be performed using ultrasound, CT, or fluoroscopic guidance. Fluoroscopy and computed tomography generally have limited availability, increased expense, exposure to radiation, and perhaps the limiting factor, the need to transfer critically ill patients to the radiology suite. A 2010 study performed by Donkol et al. demonstrated success rates for CT (93%), US (46%), and fluoroscopy (62%). Though US had the lowest success rate, it remains the only option for those critically ill who cannot tolerate transportation outside the intensive care unit or an immediate cholecystectomy. Also, at most experienced centers that rate of procedural success with ultrasound guidance is far higher than 46%.

The patient is positioned supine with arm abducted to an arm board. Using a convex probe at frequency range 2.5–6 MHz, the gallbladder is evaluated for the best approach. Confirm liver

In the transhepatic approach, the catheter is to pass via the bare area of the liver in order to access the gallbladder. This may be done subcostally, thought the intercostal approach is preferred to minimize tube dislodgement and kinking. When using an intercostal approach, care must be taken to avoid puncturing the diaphragm, pleura or the intercostal neurovascular bundle as it passes inferior to the rib. The transhepatic approach decreases the risk of bile leaks and colon injury, which are more common in the transperitoneal approach [1, 2, 12, 19].

The transperitoneal approach is a direct puncture of the gallbladder, often used in patients who have coagulopathies, which preclude the transhepatic approach. The gallbladder must be distended and in close proximity to the abdominal wall [1, 2, 12, 19]. In the author's opin-

Once a trajectory has been planned, the patient is then sterilely prepped and draped in a supine position with right arm abducted [11]. The entry site is anesthetized with 1–2% buffered lidocaine.

There are two techniques used for placement of the pigtail catheter into the gallbladder—the

The modified Seldinger technique consists of inserting a needle into the gallbladder under direct US guidance (**Figure 1**). The most common needle is an 18 G 10 cm hollow core needle, although smaller gauge needles can be used with 0.018 inch access systems. Aspiration of the needle should confirm bilious return. A 0.035 inch guidewire is then inserted through the needle into the gallbladder lumen. The wire should be seen looping in the gallbladder lumen with ultrasound. Use a scalpel to create a skin nick at the needle entry site and bluntly dilate this with a Kelly clamp or curved snap. The needle is removed and dilators of increasing diameters are advanced over the wire just into the gallbladder in order to dilate a tract large enough to accommodate a drain. The most common drain sizes are 8, 10 and 12 F, with larger sizes chosen for more viscous fluid. The catheter is advanced over the wire under ultrasound guidance. Once the tip enters the gallbladder, the catheter is unlocked from the inner stiffener and further advanced over the wire. The wire and stiffener are then removed, and pulling on the drain string forms

Higher rates of bleeding are associated with the transhepatic approach [13].

ion, the transhepatic, intercostal approach is the safest and preferred method.

modified Seldinger technique, and the trocar technique.

Procedure-associated morbidity can be extremely high in a critically ill patient population [14]. Although this is the best alternative to preventing/treating biliary sepsis aside from surgery, great care must be taken post procedure to avoid complications. Bed rest is needed (typically 2–4 h) with regular monitoring of vital signs and adequate pain control. The patient should be monitored for new or worsening chest /right upper quadrant pain, dyspnea, shortness of breath, and red or tarry stool. These typically occur 1–72 h after the procedure [11]. Catheter dislodgement is the most common complication and may be due to patient movement, failure to protect the catheter during transportation, or inadequate fixation of the catheter. Timely removal of the catheter after mature tract formation can decrease biliary peritonitis secondary to bile leakage [9].

Patients who are not candidates for cholecystectomy and continue to have indwelling cholecystostomy tubes need to have routine exchanges of the catheter to prevent obstruction and/or encrustation. These are typically performed every 8–12 weeks, with shorter intervals in patients who occlude their catheters. In addition to daily normal saline flushes, Ursodiol can be given to thin bile and prevent crystal formation in patients who have issues with catheter patency.

Bedside Percutaneous Cholecystostomy http://dx.doi.org/10.5772/intechopen.70500 115

There are no absolute contraindications to percutaneous cholecystostomy. Relative contraindications of PC include hemorrhage or uncorrectable bleeding diathesis, and pericholecystic abscess. A gallbladder filled with stones might prevent catheter insertion. Presence of gall-

The presence of ascites was once thought to increase the risk of failed tract maturation; however, a 2015 study demonstrated that it is not increased when compared to patients without ascites

Tube dislodgement is a frequent complication (**Figure 2**), seen as high as 80% [13]. Friedrich et al found tube dislodgement to be 59% in their study [14]. The method used for placement was proven to be unrelated to rates of dislodgement [14]. The locking loop catheters are preferred to reduce the risk of dislodgment as the catheter dislodgment tends to occur in a higher rate here

**Figure 2.** Intraoperative fluoroscopic image obtained after cholecystectomy tube placement. Contrast is seen within the

bladder tumor is also a relative contraindication as tumor seeding might occur.

**8. Contraindications**

**9. Complications**

gallbladder lumen after injection into the catheter.

[15].

The catheter should be flushed daily with 5–10 mL with sterile saline to avoid occlusion [9].

Cholangiography can be used to assess patency of the cystic duct, presence of gallstones, and catheter position days after the procedure or when the patient has stabilized [11]. Using the tube for diagnostic studies is not recommended until the patient has clinically improved from their infection.

The catheter cannot be removed for at least 6 weeks [11], unless done during a cholecystectomy. Prior to removal, two things must be established: patency of the cystic duct and maturity of the transhepatic/transperitoneal tract. These are accomplished with fluoroscopic evaluation via fistulography. This is performed with injection of contrast material to evaluate patency of the cystic and common bile ducts. To evaluate tract maturity, a guidewire is placed through the catheter and looped in the gallbladder lumen and the catheter is removed. Tract maturation is evaluated by injecting contrast through a sheath as is it withdrawn over the wire. Care must be taken to preserve wire access to the gallbladder. The tract is considered mature if there is no leakage into the peritoneal cavity. If leakage is identified, a new catheter is placed and the process repeated until maturation is confirmed [12]. If the tract is mature and the cystic duct and CBD are patent, then many operators will opt for a clamp trial of the catheter.

## **7. Outcomes**

Response rates vary widely in the literature from 8 to 100% [16]. Atara et al. found the success rate to be as high as 79% in their study [4]. Patients with clinical signs and localized symptoms to the right upper quadrant are more likely to respond to PC. Patients in the intensive care unit were less likely to respond to PC [16, 20]. When the gallbladder is the only source of infection, the response is dramatic. Positive response to treatment was seen in up to 59% of critically ill patients according to a study by Boland et al. [9].

A study by Atara et al. suggests that scheduled cholecystectomy after PC may prevent biliary complications over the long term. They demonstrated a post-surgery rate of 5.6% and mortality rate was 2.8%, both significantly lower than found in the literature [4].

While recurrent rates of are low for additional episodes of acute appendicitis in the general population, the populations with high surgical mortality and morbidity have higher incidences of recurrent attacks. Removing the gallbladder ensures further episodes of biliary sepsis that can also carry similarly high mortality rates do not occur [16].

Patients who are not candidates for cholecystectomy and continue to have indwelling cholecystostomy tubes need to have routine exchanges of the catheter to prevent obstruction and/or encrustation. These are typically performed every 8–12 weeks, with shorter intervals in patients who occlude their catheters. In addition to daily normal saline flushes, Ursodiol can be given to thin bile and prevent crystal formation in patients who have issues with catheter patency.

## **8. Contraindications**

great care must be taken post procedure to avoid complications. Bed rest is needed (typically 2–4 h) with regular monitoring of vital signs and adequate pain control. The patient should be monitored for new or worsening chest /right upper quadrant pain, dyspnea, shortness of breath, and red or tarry stool. These typically occur 1–72 h after the procedure [11]. Catheter dislodgement is the most common complication and may be due to patient movement, failure to protect the catheter during transportation, or inadequate fixation of the catheter. Timely removal of the catheter after mature tract formation can decrease biliary peritonitis secondary

The catheter should be flushed daily with 5–10 mL with sterile saline to avoid occlusion [9]. Cholangiography can be used to assess patency of the cystic duct, presence of gallstones, and catheter position days after the procedure or when the patient has stabilized [11]. Using the tube for diagnostic studies is not recommended until the patient has clinically improved from

The catheter cannot be removed for at least 6 weeks [11], unless done during a cholecystectomy. Prior to removal, two things must be established: patency of the cystic duct and maturity of the transhepatic/transperitoneal tract. These are accomplished with fluoroscopic evaluation via fistulography. This is performed with injection of contrast material to evaluate patency of the cystic and common bile ducts. To evaluate tract maturity, a guidewire is placed through the catheter and looped in the gallbladder lumen and the catheter is removed. Tract maturation is evaluated by injecting contrast through a sheath as is it withdrawn over the wire. Care must be taken to preserve wire access to the gallbladder. The tract is considered mature if there is no leakage into the peritoneal cavity. If leakage is identified, a new catheter is placed and the process repeated until maturation is confirmed [12]. If the tract is mature and the cystic duct

and CBD are patent, then many operators will opt for a clamp trial of the catheter.

Response rates vary widely in the literature from 8 to 100% [16]. Atara et al. found the success rate to be as high as 79% in their study [4]. Patients with clinical signs and localized symptoms to the right upper quadrant are more likely to respond to PC. Patients in the intensive care unit were less likely to respond to PC [16, 20]. When the gallbladder is the only source of infection, the response is dramatic. Positive response to treatment was seen in up to 59% of critically ill

A study by Atara et al. suggests that scheduled cholecystectomy after PC may prevent biliary complications over the long term. They demonstrated a post-surgery rate of 5.6% and mortal-

While recurrent rates of are low for additional episodes of acute appendicitis in the general population, the populations with high surgical mortality and morbidity have higher incidences of recurrent attacks. Removing the gallbladder ensures further episodes of biliary sep-

ity rate was 2.8%, both significantly lower than found in the literature [4].

sis that can also carry similarly high mortality rates do not occur [16].

to bile leakage [9].

114 Bedside Procedures

their infection.

**7. Outcomes**

patients according to a study by Boland et al. [9].

There are no absolute contraindications to percutaneous cholecystostomy. Relative contraindications of PC include hemorrhage or uncorrectable bleeding diathesis, and pericholecystic abscess. A gallbladder filled with stones might prevent catheter insertion. Presence of gallbladder tumor is also a relative contraindication as tumor seeding might occur.

The presence of ascites was once thought to increase the risk of failed tract maturation; however, a 2015 study demonstrated that it is not increased when compared to patients without ascites [15].

## **9. Complications**

Tube dislodgement is a frequent complication (**Figure 2**), seen as high as 80% [13]. Friedrich et al found tube dislodgement to be 59% in their study [14]. The method used for placement was proven to be unrelated to rates of dislodgement [14]. The locking loop catheters are preferred to reduce the risk of dislodgment as the catheter dislodgment tends to occur in a higher rate here

**Figure 2.** Intraoperative fluoroscopic image obtained after cholecystectomy tube placement. Contrast is seen within the gallbladder lumen after injection into the catheter.

than in other organs [4, 9]. This is mostly due to the degree of respiratory motion at this location in the abdomen and, in the author's experience, is encountered less frequently with the intercostal approach compared with the subcostal approach. Critically ill patients are also prone to altered mental status and dislodgement can be secondary to forceful removal by the patient [9].

in the absence of stones with these inflammatory findings, acalculous cholecystitis should be considered. These findings can also be seen in computed tomography (**Figure 5**). Hepatobiliary

Bedside Percutaneous Cholecystostomy http://dx.doi.org/10.5772/intechopen.70500 117

**Figure 5.** Contrast enhanced axial CT image demonstrating a distended gallbladder with wall thickening and surrounding

**Figure 6.** 99mTc-HIDA scintigraphy demonstrates nonvisualization of the gallbladder after 1 h. Morphine was then

scan is used in equivocal cases (**Figure 6**) [6].

**11. Equipment needed**

administered with persistent nonvisualization.

• Sterile field cover and/or towels;

• Sterile probe cover and sterile ultrasound gel;

• Sterilizing material and applicant (chlorhexhidine stick, betadine with swabs);

• Ultrasound machine;

• Sterile biopsy tray;

• Sterile gauze;

fat stranding.

• 22 gauge needle; • 3 10 cc syringes;

Complications directly related to placement of a cholecystostomy tube include bile leak, cholangitis, bleeding, tube dislodgment, hematoma, biloma, seroma, pneumothorax, injury to surrounding organs including bowel perforation, abscess formation, and pain at the procedure site [14, 16].

Major complications include sepsis (3%), bile leak leading to peritonitis (4%), major bleeding (3%), and death (10%) [14].

Bradycardia and hypotension can also occur from gallbladder manipulation.

#### **10. Peri-procedural imaging**

The diagnosis of acute cholecystitis begins with suspicion on the basis of right upper quadrant pain and tenderness. The primary imaging modality is ultrasound, which can demonstrate stones (**Figure 3**), wall thickening, pericholecystic fluid (**Figure 4**), gallbladder distension, and

**Figure 3.** Ultrasound imaging demonstrates numerous shadowing stones within a distended gallbladder in a patient with right upper quadrant pain.

**Figure 4.** Ultrasound imaging demonstrates distended gallbladder with surrounding pericholecystic fluid in a patient with right upper quadrant pain and biliary ductal dilation.

in the absence of stones with these inflammatory findings, acalculous cholecystitis should be considered. These findings can also be seen in computed tomography (**Figure 5**). Hepatobiliary scan is used in equivocal cases (**Figure 6**) [6].

**Figure 5.** Contrast enhanced axial CT image demonstrating a distended gallbladder with wall thickening and surrounding fat stranding.

**Figure 6.** 99mTc-HIDA scintigraphy demonstrates nonvisualization of the gallbladder after 1 h. Morphine was then administered with persistent nonvisualization.

## **11. Equipment needed**


than in other organs [4, 9]. This is mostly due to the degree of respiratory motion at this location in the abdomen and, in the author's experience, is encountered less frequently with the intercostal approach compared with the subcostal approach. Critically ill patients are also prone to altered mental status and dislodgement can be secondary to forceful removal by the patient [9]. Complications directly related to placement of a cholecystostomy tube include bile leak, cholangitis, bleeding, tube dislodgment, hematoma, biloma, seroma, pneumothorax, injury to surrounding organs including bowel perforation, abscess formation, and pain at the pro-

Major complications include sepsis (3%), bile leak leading to peritonitis (4%), major bleeding

The diagnosis of acute cholecystitis begins with suspicion on the basis of right upper quadrant pain and tenderness. The primary imaging modality is ultrasound, which can demonstrate stones (**Figure 3**), wall thickening, pericholecystic fluid (**Figure 4**), gallbladder distension, and

**Figure 4.** Ultrasound imaging demonstrates distended gallbladder with surrounding pericholecystic fluid in a patient

**Figure 3.** Ultrasound imaging demonstrates numerous shadowing stones within a distended gallbladder in a patient

Bradycardia and hypotension can also occur from gallbladder manipulation.

cedure site [14, 16].

116 Bedside Procedures

(3%), and death (10%) [14].

with right upper quadrant pain.

**10. Peri-procedural imaging**

with right upper quadrant pain and biliary ductal dilation.


cholecystostomy, sphincterostomy, or gallstone dissolution depending on the etiology. Briefly discussed was the necessity of cholecystostomy, which can be performed at bedside in criti-

PC is a safe and effective procedure in critically ill patients in the acute phase of cholecystitis with a high technical success rate and gives added benefit of better future surgical survival

Having the knowledge and skill to adequately perform this procedure is essential, especially

, Syed Aziz-Ur Rahman3

1 Department of Diagnostic and Interventional Imaging, The University of Texas at Houston,

[1] Little MW, Briggs JH, Tapping CR, Bratby MJ, Anthony S, Phillips-Hughes J, Uberoi R. Percutaneous cholecystostomy: The radiologist's role in treating acute cholecystitis. Clinical Radiology. 2013 Jul;**68**(7):654-660. DOI: 10.1016/j.crad.2013.01.017. Epub 2013

[2] Blanco PA, Do Pico JJ. Ultrasound-guided percutaneous cholecystostomy in acute cholecystitis: Case vignette and review of the technique. Journal of Ultrasound. 2015;**18**(4):311-

[3] Indar AA, Beckingham IJ. Acute Cholecystitis. BMJ : British Medical Journal. 2002;

[4] Atara E, Bachara GN, Berlina S, Neimana C, Bleich-Belenkya E, Litvina S, Knihznika M, Belenkya A, Ramb E. Percutaneous cholecystostomy in critically ill patients with acute cholecystitis: Complications and late outcome Units of Vascular and Interventional Radiology, Department of Diagnostic Radiology, Rabin Medical Center, Hasharon and Beilinson Hospitals, Petach Tikva, Israel Department of Surgery, Rabin Medical Center, Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Clinical Radiology. 2014 Jun;**69**(6):e247-e252. DOI: 10.1016/j.crad.2014.01.012. Epub 2014 Mar 1

and Joshua Kuban2

\*

Bedside Percutaneous Cholecystostomy http://dx.doi.org/10.5772/intechopen.70500 119

and ability to remove duct stones without creating additional access [18].

3 Baylor College of Medicine Radiology Department, Houston, Texas, USA

cally ill patients who are not surgical candidates.

in patients with septic shock in need of source control.

, Rahul Sheth2

2 MD Anderson Cancer Center, Houston, Texas, USA

315. DOI: 10.1007/s40477-015-0173-2

**325**(7365):639-643. Print

\*Address all correspondence to: jdkuban@mdanderson.org

**Author details**

Michelle Maneevese1

Houston, Texas, USA

**References**

Mar 21

## **12. Bedside set-up tips and pitfalls**

As with all bedside procedures, it is vital that you have all materials needed with you. An example of tray set up is given in **Figure 7**. While many bedside procedures require tools that can be found on the ward, most of the items necessary for PC placement are only found in the IR suite or OR. Therefore, it is wise to bring a variety of tools with you, including catheters of various sizes, extra wires, dilators, and gelfoam.

Make sure to position the ultrasound screen in a convenient location that allows you to quickly look from the monitor to the access site.

Having a sterile assistant is very helpful in this procedure. While catheter exchanges over a wire are easy in the IR suite, the sterile field is more limited at the bedside and an assistant can help maintain proper sterile technique during the more challenging portions of the procedure. Have an alcohol wipe available in case the back end of the wire goes off the sterile field.

**Figure 7.** Example of tray set-up for percutaneous cholecystostomy placement.

## **13. Conclusion**

The gallbladder is a small organ with much pathology. Possible treatment options for acute cholecystitis include: open versus laparoscopic cholecystectomy or open versus percutaneous cholecystostomy, sphincterostomy, or gallstone dissolution depending on the etiology. Briefly discussed was the necessity of cholecystostomy, which can be performed at bedside in critically ill patients who are not surgical candidates.

PC is a safe and effective procedure in critically ill patients in the acute phase of cholecystitis with a high technical success rate and gives added benefit of better future surgical survival and ability to remove duct stones without creating additional access [18].

Having the knowledge and skill to adequately perform this procedure is essential, especially in patients with septic shock in need of source control.

## **Author details**

• 18 G needle;

118 Bedside Procedures

• Kelly clamp;

**13. Conclusion**

• Scalpel;

• 1–2% buffered lidocaine;

dilator, 10 F locking pigtail catheter.

**12. Bedside set-up tips and pitfalls**

various sizes, extra wires, dilators, and gelfoam.

quickly look from the monitor to the access site.

**Figure 7.** Example of tray set-up for percutaneous cholecystostomy placement.

• Trocar technique: 10 F locking pigtail catheter with needle trocar;

• Seldinger technique: 18 G 10–15 cm needle, 0.035′ guidewire with 3 mm j-tip, 8 and 10 F

As with all bedside procedures, it is vital that you have all materials needed with you. An example of tray set up is given in **Figure 7**. While many bedside procedures require tools that can be found on the ward, most of the items necessary for PC placement are only found in the IR suite or OR. Therefore, it is wise to bring a variety of tools with you, including catheters of

Make sure to position the ultrasound screen in a convenient location that allows you to

Having a sterile assistant is very helpful in this procedure. While catheter exchanges over a wire are easy in the IR suite, the sterile field is more limited at the bedside and an assistant can help maintain proper sterile technique during the more challenging portions of the procedure. Have an alcohol wipe available in case the back end of the wire goes off the sterile field.

The gallbladder is a small organ with much pathology. Possible treatment options for acute cholecystitis include: open versus laparoscopic cholecystectomy or open versus percutaneous Michelle Maneevese1 , Rahul Sheth2 , Syed Aziz-Ur Rahman3 and Joshua Kuban2 \*

\*Address all correspondence to: jdkuban@mdanderson.org

1 Department of Diagnostic and Interventional Imaging, The University of Texas at Houston, Houston, Texas, USA

2 MD Anderson Cancer Center, Houston, Texas, USA

3 Baylor College of Medicine Radiology Department, Houston, Texas, USA

## **References**


[5] De U. Evolution of cholecystectomy: A tribute to Carl August Langenbuch. Indian Journal of Surgery. 2004;**66**:97-100

[19] Venara A, Carretier V, Lebigot J, Lermite E, Technique and indications of percutaneous cholecystostomy in the management of cholecystitis in 2014. Journal of Visceral Surgery.

Bedside Percutaneous Cholecystostomy http://dx.doi.org/10.5772/intechopen.70500 121

[20] Hultman SC, Herbst AC, McCall MC, Mauro AM. The efficacy of percutaneous cholecystostomy in critically ill patients. The American Surgeon. 1996;**62**:263-269

2014 Dec;**151**(6):435-439; ISSN 1878-7886


[19] Venara A, Carretier V, Lebigot J, Lermite E, Technique and indications of percutaneous cholecystostomy in the management of cholecystitis in 2014. Journal of Visceral Surgery. 2014 Dec;**151**(6):435-439; ISSN 1878-7886

[5] De U. Evolution of cholecystectomy: A tribute to Carl August Langenbuch. Indian Journal

[6] Elyaderani M, Gabriele OF. Percutaneous cholecystostomy and cholangiography in

[7] Venara A, Carretier V, Lebigot J, Lermite E. Technique and indications of percutaneous cholecystostomy in the management of cholecystitis in 2014. Journal of Visceral Surgery.

[8] Laurila JJ, Ala-Kokko TI, Laurila PA, et al. Histopathology of acute acalculous cholecys-

[9] Boland GW, Lee MJ, Leung J, Mueller PR. Percutaneous cholecystostomy in critically ill patients: Early response and final outcome in 82 patients. American Journal of

[10] Boland GW, Lee MJ, Mueller PR, Dawson SL, Gaa J, Lu DS, Gazelle GS. Gallstones in critically ill patients with acute calculous cholecystitis treated by percutaneous cholecystostomy: Nonsurgical therapeutic options. American Journal of Roentgenology.

[11] Kandarpa K, Machan L. Handbook of Interventional Radiologic Procedures. Lippincott

[12] Akhan O, Akıncı D, Özmen MN. Percutaneous cholecystostomy. European Journal of Radiology. 2002 Sep;**43**(3):229-236; Department of Radiology, School of Medicine, Hacettepe

[13] McKay A, Abulfaraj M, Lipschitz J. Short- and long-term outcomes following percutaneous cholecystostomy for acute cholecystitis in high-risk patients. Surgical Endoscopy.

[14] Friedrich AU, Baratta KP; Lewis, J; Karam AR, Hudlin M, Litwin DE, Cahan MA. Cholecystostomy treatment in an ICU population: Complications and risks. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2016 Oct;**26**(5):410-416

[15] Duncan CT, et al. Outcomes of percutaneous cholecystostomy in the presence of ascites. Journal of Vascular and Interventional Radiology. 2016 Apr;**27**(4):562-566.e1. DOI:

[16] Toh Y, Yano K, Takesue F, et al. Abdominal surgery for patients on maintenance hemo-

[17] Yamakawa T, Fukuda N. History of surgery for cholelithiasis: From the era of cholecystostomy to laparoscopic surgery. Nihon Geka Gakkai Zasshi. 2000 Dec;**101**(12):877-881

[18] Zaroura S, Imama A, Kouniavskya G, Lina G, Zbara A, Mavora E. Percutaneous Cholecystostomy in the Management of High-risk Patients Presenting with Acute Cholecystitis: Timing and Outcome at a Single Institution. Rehovot: Department of Surgery, Kaplan

2012 May;**26**(5):1343-1351. DOI: 10.1007/s00464-011-2035-0. Epub 2011 Nov 17

Williams & Wilkins; Balitmore, Maryland. 2010. ISBN: 0781768160

patients with obstructive jaundice. Radiology. 1979;**130**:601-602

2014;**151**(6):435-439. DOI: 10.1016/j.jviscsurg.2014.06.003

1994;**162**:1101-1103. DOI: 10.2214/ajr.162.5.8165990

10.1016/j.jvir.2015.12.004. Epub 2016 Feb 15

dialysis. Surgery Today. 1998;**28**:268-272

Medical Center; 2017

titis in critically ill patients. Histopathology. 2005;**47**:485-492

of Surgery. 2004;**66**:97-100

120 Bedside Procedures

Roentgenology. 1994;**163**:339-342

University, Ankara, Turkey

[20] Hultman SC, Herbst AC, McCall MC, Mauro AM. The efficacy of percutaneous cholecystostomy in critically ill patients. The American Surgeon. 1996;**62**:263-269

**Chapter 7**

**Provisional chapter**

**Intra-Abdominal Pressure Monitoring**

**Intra-Abdominal Pressure Monitoring**

DOI: 10.5772/intechopen.70701

Pancreatitis, inflammatory processes or retroperitoneal haemorrhage, paralytic ileus, ascites, severe visceral oedema caused by extreme fluid replacement, blunt abdominal trauma, peritonitis, or even massive transfusion can be found among the triggering factors of intra-abdominal hypertension and abdominal compartment syndrome (ACS). The only possible way of establishing the diagnosis is to measure the intra-abdominal pressure (IAP), a widespread manner of which is the measurement through the bladder. In our works, we wanted to study whether the method of continuous intra-abdominal pressure monitoring is feasible within the everyday practice of diagnosing the conditions having increased intra-abdominal pressure. The globally accepted pressure measurement carried out through a urinary catheter and its classical so-called intermittent form has been employed worldwide in the intensive care units and surgical wards. The procedure is simple, yet time consuming, and the catheter connections and disconnections are sources of infection. The measurement results provide information only on the individual pressure values of the predetermined measurement dates. In order to eliminate these weaknesses and for the safe and quick measurements, the classical technique was replaced by a completely new method: the continuous intra-abdominal pressure monitoring. In order to determine the objectivity of the continuous intra-abdominal pressure measurement technique, we carried out a validation study on surgical patients with normal and elevated intra-abdominal pressures. The pressure was determined by both methods in case of all patients. Significant difference could not be observed between the results of the intermittent and of the new technique. In this chapter, we want to discuss in detail of this validation study appointing the strong advantages of the new monitoring process. Measurement of the intra-abdominal pressure is essential in the differential diagnosis of acute abdominal pathologies. Pressure measurement through urinary catheters for the monitoring of the intra-abdominal pressure, especially its continuous variant, is an excellently applicable

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

**Keywords:** intra-abdominal pressure, intermittent intra-abdominal pressure measurement, continuous intra-abdominal pressure monitoring, intra-abdominal hypertension, abdominal

method. Introduction into the daily clinical routine is highly recommended.

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70701

compartment syndrome

Zsolt Bodnar

**Abstract**

Zsolt Bodnar

**Provisional chapter**
