LUMBAR PUNCTURE NOTE
Indications: ***
Consent obtained: ***
Operators:
1) ***
2) ***
Ultrasound guidance: ***
Images saved: ***
Landmarks: midline between superior iliac crests by palpation
Pre-procedure diagnosis: ***
Team pause:
At ***, prior to the beginning of the procedure, the team paused to verify the patient’s identity, the procedure to be performed (in accordance with the consent obtained prior to procedure,) and the correct side/site. This information was verified by the patient's nurse and the patient himself/herself.
Procedure:
Relevant imaging was reviewed and in combination with physical exam the patient was not thought to have increased intracranial pressure. The patient was positioned in the lateral decubitus position. Using anatomical landmarks by palpating the iliac crests a space was located in the midline between L3 and L4. The site was prepped with chlorhexidine and sterilely draped.
Using sterile technique *** mLs of 1% lidocaine was used to raise a wheal at the site of entry and the needle tract was anesthetized. Using a spinal needle the subarachnoid space was entered and *** mLs of CSF were withdrawn and sent for studies. A sterile dressing was applied.
Findings:
Opening pressure: *** cmH2O
CSF appearance: ***
Attempts: ***
Studies sent:
- cell count and differential
- CSF glucose
- CSF protein
- gram stain and culture
- additional studies: ***
I was present for the entire procedure. There were no immediate or anticipated complications.
I spent 50 minutes with the patient.