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PubMed2004

Routine lumbar puncture in children with febrile seizures in Ghana: should it continue?

OBJECTIVES: Performing routine lumbar punctures in children with febrile seizures has been controversial. This study aimed to determine the positive yield of lumbar punctures in a setting where routine lumbar puncture is routinely carried out and to determine if any other parameter could help differentiate bacterial meningitis from the various other diagnoses of children who presented with a febrile seizure. DESIGN: A prospective study was carried out among children aged three months to 15 years of age, hospitalized at the Komfo Anokye Teaching Hospital in Kumasi, Ghana, between July and August 2000. RESULTS: There was a 10.2% (n = 19) positive yield for bacterial meningitis with a case fatality rate of 36.8% (n = 7). Cerebral malaria, which is not easily distinguishable from bacterial meningitis, accounted for 16.1% (n = 30) of the children. Twenty percent of bacterial meningitis patients had a positive blood smear for malaria. The indication for doing a lumbar puncture was similar in both cerebral malaria and bacterial meningitis patients. Signs of meningism were not the primary reason for carrying out a lumbar puncture, even in the group of children who had bacterial meningitis. CONCLUSION: Performing routine lumbar punctures may still have a role to play in the management of children with febrile seizures.

Child↗
PubMed2006

Image-guided puncture technique for the superior temporomandibular joint space: value of cone beam computed tomography (CBCT).

OBJECTIVE: Temporomandibular joint (TMJ) disk perforation or adhesion requires arthrographic examination. However, puncture of the TMJ may result in damaging penetration of the middle cranial fossa. We investigated the effectiveness of penetrating the superior TMJ space using a safe image-guided puncture technique (IGPT). STUDY DESIGN: Fifty-two patients underwent cone beam computed tomography (CBCT) examination. Optimum angles and distances from the puncture site to the thinnest point of the glenoid fossa to penetrate the superior joint space were measured using three-directional images. RESULTS: Puncturing the superior articular cavity was immediately successful in 50 cases. Image measurements gave an average horizontal angle of 8.0 degrees (standard deviation [SD]: 9.2), an average coronal angle of 16 degrees (SD: 11.3), and an average distance of 27 mm (SD: 2.8). CONCLUSION: Variation in puncture angle among individuals indicated that CBCT examination is necessary preceding TMJ puncture. Preliminary clinical application has demonstrated the safety of IGPT using CBCT.

Adult↗
PubMed1991

Complications of direct brachial artery puncture for arteriography: a comparison of techniques.

Direct brachial artery puncture is used increasingly for day-case arteriography and patients with severe aorto-iliac disease. In expert hands low complication rates are reported, but the risks of brachial artery puncture may be higher when it is performed by less experienced operators. Over a 2 year period 49 direct brachial artery punctures were performed for arteriography. In 27 cases catheters were inserted directly over a guide-wire via a variable puncture site. In 22 cases catheters were inserted through an introducer sheath via a high brachial puncture. Significant complications requiring active treatment or surgical intervention occurred in three (11%) cases where direct catheter insertion was used. There were no complications when an introducer sheath was used. Percutaneous high brachial aortography using an introducer sheath is a safer technique when brachial artery puncture is performed infrequently.

Angiography↗
PubMed2004

Lymph sampling and lymphangiography via EUS-guided transesophageal thoracic duct puncture in a swine model.

BACKGROUND: The thoracic duct plays an important role in fluid balance, lipid absorption, and transport of immunologically active cells. The thoracic duct is difficult to access but is readily identified by EUS. The present study assessed the feasibility of EUS identification and EUS-guided puncture of the thoracic duct in a swine model. METHODS: Transesophageal EUS-guided thoracic duct puncture was attempted in 3 animals under fluoroscopy. In two animals, the thoracic duct was identified by cutdown in the neck; in the third animal, EUS-guided puncture was performed under fluoroscopy alone. In one animal, the thoracic duct was opacified by injecting contrast medium. In the second animal, thoracic duct was injected with patent blue and contrast medium. OBSERVATIONS: Thoracic duct was identified and punctured successfully in all 3 animals. In the first animal, contrast medium containing lymph was aspirated. In the second animal, lymph containing patent blue was aspirated, and, in the third animal, successful puncture was confirmed by obtaining a lymphangiogram. CONCLUSIONS: This pilot study in an animal model demonstrates that transesophageal EUS-guided puncture of the thoracic duct is feasible and that the technique can be used for lymph sampling and/or lymphangiography.

Animals↗
PubMed1979

Recommended site and depth of newborn heel skin punctures based on anatomical measurements and histopathology.

The heels of 40 children (0.56--13.15 kg), 35 of whom were newborn infants and 28 of whom had 2--20 visible skin punctures, were examined at necropsy, and the thickness of the tissue layers was measured with a metric vernier caliper. Histological examination showed that uncomplicated skin-puncture wounds heal with minimum scarring and no neuroma formation. 1 infant had an infected puncture track extending into the calcaneus and resulting in cellulitis and focal calcaneal necrotising chondritis. The skin's primary blood-supply is located at the junction of the dermis and subcutaneous tissue, and the distance from the surface of the heel to this junction was quite constant (0.35--1.6 mm). However, the distance from the skin surface to the calcaneus increased with infant weight (in the smallest infant it was 2.4 mm), and at the posterior curvature of the heel it was half that from the plantar surface to the calcaneus. The calcaneus rarely extended lateral to a line drawn posteriorly from a point midway between the 4th and 5th toes and running parallel to the lateral aspect of the heel or medial to a line extending posteriorly from the middle of the great toe and running parallel to the medial surface of the heel. Therefore, in order to avoid calcaneal puncture and the risk of osteochondritis, heel puncture in the newborn should be done: (1) on the most medial or lateral portions of the plantar surface of the heel; (2) no deeper than 2.4 mm; (3) not on the posterior curvature of the heel; and (4) not through previous puncture sites that may be infected.

Abscess↗
PubMedDate not supplied

[Lumbar post-puncture syndrome].

About 30% of lumbar punctures are complicated by the lumbar puncture syndrome the main symptom of which is a characteristically posture-dependent headache (the so-called "spinal headache"), sometimes accompanied by nausea, vomiting and stiff neck. The syndrome usually begins in the days which follow lumbar puncture and subsides within 10 days. The most common pathogenetic theory is that perforation of the dura mater results in CSF leakage responsible for a fall in intrathecal pressure. Treatment of the lumbar puncture syndrome consists of rest in supine position and copious hydration, usually by the oral route. The epidural blood patch technique is seldom used. Prevention relies entirely on the use of small calibre lumbar puncture needles; keeping the patient lying supine after the puncture is a classical recommendation, but its preventive value has not yet been fully demonstrated.

Headache↗
PubMed2002

Optimal set-up for ultrasound guided punctures using new scanner applications: an in-vitro study.

OBJECTIVE: To investigate if US-visualisation of the needle tip echo during US-guided punctures could be improved by use of new technological applications. METHOD: an US-guided 18 G Trocar needle was inserted into targets of a puncture phantom. The punctures were performed in series of 10 using different settings of the US-scanner (GE Logic 700 Expert). At 7-cm of puncture depth the quality of the echo was tested using four different settings; normal (N), N + automatic tissue optimising (ATO), coded harmonic imaging (CHI), CHI + ATO and at 13-cm of puncture depths six different settings; N, N + ATO, coded excitation (CE), CE+ATO, CHI, CHI+ATO. In total 100 (40 + 60) images were randomly numbered and read independently by three radiologists with regard to scoring of the quality of the echoes from the needle tip, needle shaft and the target. RESULTS: US visualisation of the needle tip was significantly (P < 0.005) improved as compared to normal settings (N) when the settings of ATO and CE were used. CHI resulted in the lowest score. A high agreement between observers was registered. Similar results were registered with regard to scorings from the needle shaft and target. CONCLUSION: Not only changes of needle designs and puncture techniques can enhance echoes from the needle but also changes in the settings of the US-scanner with the use of new technological applications can improve visualisation of the needle echo.

Humans↗
PubMed1991

Percutaneous cholecystostomy: does transhepatic puncture preclude a transperitoneal catheter route?

Percutaneous cholecystostomy is now commonly performed for the diagnosis and treatment of gallbladder and biliary disorders. The optimal method and route of percutaneous cholecystostomy catheter placement, however, remain controversial and may depend on the indication for the procedure. The ability to predict traversal of the extraperitoneal plane of fixation ("bare area") between the liver and gallbladder with a transhepatic approach was investigated. With sonographic guidance, 21 transhepatic catheterizations were attempted: 19 in cadavers and two in patients who subsequently underwent cholecystectomy. In all cases, 8-F or 5-F self-retaining catheters were used. At autopsy or surgery, the catheter course and gallbladder puncture site were evaluated. Of 21 punctures, 19 (90%) were transhepatic and two (10%) were transperitoneal. Among the 19 transhepatic punctures, eight catheters (42%) traversed the bare area, while 11 (58%) entered the free gallbladder wall adjacent to the serosal attachment. There were four instances of guide-wire dislodgment during catheter placement; all occurred following puncture of the free wall of the gallbladder. No guide-wire dislodgment occurred when the bare area was transversed. Transhepatic gallbladder puncture does not prevent puncture of the free gallbladder surface. However, the liver and bare area do seem to provide guide-wire stability during catheter placement.

Adult↗
PubMed2004

A randomized trial assessing the value of ultrasound-guided puncture of the femoral artery for interventional investigations.

Using a prospectively collected database of patients undergoing diagnostic or therapeutic angiography via transfemoral access, we sought to determine those patients who may benefit from ultrasound-guided puncture of the femoral artery. One-hundred-twelve patients with normal anticoagulation parameters were randomized in two groups. Fifty-six patients received ultrasound-guided puncture of the femoral artery, 56 patients underwent traditional palpation-guided vessel cannulation. Parameters assessed included procedure-time, number of attempts for successful puncture, intensity of the arterial pulse, previous ipsilateral punctures, history and risk factors of arteriosclerosis and leg circumference at the site of puncture. The data was analyzed by using outcome measures according to evidence-based medicine criteria. Only in patients with weak arterial pulse and thoses with a leg circumference of 60 cm or greater ultrasound guidance significantly decreased the number of attempts needed as well as the time for successful arterial puncture. In both patient subgroups, the number needed to treat (NNT) was 2, the absolute benefit increase (ABI) was 50 and 57%, respectively. In contrast, time for vessel cannulation was increased in patients with strong arterial pulse using ultrasound guidance. No significant differences were found with respect to diminished complications neither comparing both patient groups nor comparing risk subgroups. In conclusion ultrasound guidance for femoral artery access is recommended only in patients with a weak or absent arterial pulse and obese patients.

Databases as Topic↗
PubMed1997

Evaluation of neonates with risk for infection/suspected sepsis: is routine lumbar puncture necessary in the first 72 hours of life?

To determine whether lumbar puncture is necessary in the evaluation of neonates with risk for infection or suspected sepsis in the first 72 hours of life, we reviewed the laboratory and medical records of 506 infants who had lumbar punctures between January 1988 and December 1990. Neonates < 72 hours of age accounted for 52% of all lumbar punctures, but no case of meningitis. This led to a policy shift from routinely performing lumbar punctures to reserving them for infants with signs of severe sepsis (i.e. lethargy, hypothermia, hypotonia, poor perfusion or apnoea), specific neurological signs or clinical deterioration. This new policy was monitored prospectively from July 1991 to December 1993. Three times fewer procedures were performed in neonates < 72 hours, and there was no diagnosed or missed case of meningitis. Given that meningitis is rare within the first 72 hours of life and the yield of lumbar puncture virtually zero, we recommend that lumbar punctures be reserved for selected infants.

Age Factors↗
PubMed2002

The effect of changing pressures on dural puncture and leak with various spinal needles on an in vitro model.

Postdural puncture headache is one of the most serious complications of spinal anesthesia. In this study, spinal needles of various types and shapes were used to investigate the amount of fluid leakage in dural puncture under various levels of pressures. Dura samples received from 10 cadavers were fixed in an in vitro model. The dural punctures were inflicted with 22 G, 25 G, and 27 G Quincke; 25 G Withacre; 25 G, 27 G Pencan, and 26 G Atraucan spinal needles. The fluid, which leaked during the process, was collected under the pressures of 0, 25, 50, 100, and 150 cm H(2)O in one-hour period for each level. The holes in the dura were studied under light microscope. While 22 G and 25 G Quincke needles were used, the fluid leakage directly correlated the amount of liquid, the diameter of the needle, and the pressure used. The puncture of 25 G Withacre and 25 G Pencan presented a leakage which did not significantly vary with the liquid pressure and was of lesser amount. In 26 G Atraucan, 27 G Pencan, and 27 G Quincke inflicted punctures, little liquid was collected and it did not vary with differing pressures. Thus, no significant correlation was established between the needle diameter and the puncture. It was concluded that the sharp-ended needles could not endure changes in the pressure. However, those needles with a very thin diameter and a pencil tip were considered as safe tools for anesthetical practices.

Aged↗
PubMed1983

[Treatment of intra-abdominal abscesses by ultrasonically guided fine-needle puncture].

23 abdominal abscesses were diagnosed by ultrasound and confirmed by sonographically guided puncture. 18 cases were treated by an evacuating needle puncture and 5 cases by sonographically guided percutaneous drainage. In 12 out of 15 patients, fine needle puncture was curative without surgery required (80%). 2 out of 4 patients treated by percutaneous drainage had to be operated. Initially, 4 patients were operated, though after fine needle puncture or drainage a complete remission of symptoms and leukocytosis was observed. There were 2 complications: one hemorrhage leading to death following fine needle puncture of a pancreatic abscess and one temporary septicaemia. Sonographically guided fine needle puncture is simple and effective procedure in treatment of abdominal abscesses and should be considered as an alterative to surgery.

Abscess↗
PubMed2001

Transseptal catheterization without needle puncture.

OBJECTIVE: The aim was to see if probing the fossa ovalis for transseptal puncture during balloon mitral valvuloplasty will reduce time consumed for the procedure. DESIGN: Twenty-five patients had probing of fossa ovalis for left atrial entry (group I). In 30 patients (group II), standard needle puncture was done for left atrial entry. Puncture time and fluoroscopy time were noted and oxymetry was done. Later, a further 60 patients underwent probing of fossa ovalis for validation of the technique. RESULTS: Puncture times in groups I and II were 84.7 +/- 27.5 and 116.1 +/- 37.9 s, respectively (p < 0.02). Fluoroscopy time was 51.2 +/- 19.6 and 73.6 +/- 22.3 s in groups I and II, respectively (p < 0.03). During validation of the technique, 54 of 60 patients (90%) had successful left atrial entry through probing. Atrial level shunt was not seen. CONCLUSION: Probing the fossa achieves left atrial entry in 90% of patients. It avoids needle puncture and reduces puncture time as well as fluoroscopy time. It is a safe technique.

Adolescent↗
PubMed1996

Dural puncture with a 26-gauge spinal needle affects spread of epidural anesthesia.

Combined spinal and epidural anesthesia may increase the risk of epidurally administered drugs spreading into the subarachnoid space through the dural hole. We studied the effect of dural puncture with a 26-gauge needle on the spread of analgesia induced by epidural injection of local anesthetics. Forty patients were randomly assigned to control and dural puncture groups. In the dural puncture group, the dura was punctured with a 26-gauge Whitacre spinal needle at L2-3 but no drug was injected. In both groups, an 18-gauge epidural catheter was inserted 4 cm cephalad into the epidural space at L2-3 and 15 mL of 2% mepivacaine without epinephrine was injected. Analgesia was assessed by pinprick at 5, 10, 15, and 20 min after injection and at the end of surgery. The caudal spread of analgesia was significantly greater in the dural puncture group than in the control group 15 and 20 min after injection (P < 0.01), but the cranial spread of analgesia was not different between the two groups. We conclude that dural puncture (without drugs) using a 26-gauge Whitacre spinal needle before epidural injection increases caudal spread of analgesia induced by epidural local anesthetics.

Adult↗
PubMed1999

Epidural anesthesia and analgesia are not impaired after dural puncture with or without epidural blood patch.

UNLABELLED: Previous reports have noted a decrease in the success of subsequent epidural anesthesia and analgesia in patients who have undergone prior dural puncture with or without an epidural blood patch. Our retrospective study evaluated the success of epidural anesthesia and analgesia in all patients at the Mayo Clinic who had received a prior epidural blood patch over a 12-yr period. Each epidural blood patch patient was matched to two patients undergoing epidural anesthesia after previous dural puncture (without epidural blood patch) and to two patients undergoing epidural anesthesia after previous epidural anesthetic (without dural puncture/blood patch). These patients were matched for the duration of time between the initial procedure and subsequent epidural anesthetic and the indication (surgery, labor analgesia, postoperative analgesia) for which the subsequent epidural was performed. Subsequent epidural anesthesia was successful in 28 of 29 (96.6%, exact 95% CI 82.2%-99.9%) patients who had undergone prior blood patch, 55 of 58 (94.8%, 85.6%-98.9%) patients with a history of dural puncture, and 55 of 58 (94.8%, 85.6%-98.9%) patients who had had previous epidural anesthesia. There was no significant difference in the success rate of subsequent epidural anesthesia among groups. We conclude that prior dural puncture, with or without epidural blood patch, does not affect the success rate of subsequent epidural anesthesia. IMPLICATIONS: Patients with postdural puncture headache should not be denied the benefits of an epidural blood patch because of concerns about the impairment of subsequent epidural anesthetics. The success rate of subsequent epidural anesthesia and analgesia in patients who have undergone dural puncture with or without epidural blood patch is similar to that of patients who have undergone two prior epidural anesthetics.

Adult↗
PubMed2000

Prophylactic percutaneous sealing of lumbar postdural puncture hole with fibrin glue to prevent cerebrospinal fluid leakage in swine.

UNLABELLED: We explored the effect of fibrin glue injection at the site of dural puncture on cerebrospinal fluid (CSF) leakage in a swine model. Pigs were subjected to a lumbar dural CSF puncture in the sitting position with a 17-gauge Tuohy needle. Fibrin glue 1.4 mL was injected through the same needle into the epidural space. Evans blue dye was infused through the cisterna magna 15 min later, and the appearance of dyed CSF through the skin puncture and along the needle trajectory to the dura was inspected and categorized. In seven of eight animals, the CSF leak was sealed with fibrin glue. Control animals were injected with 1.4 mL saline. A sham operation group of animals underwent cisternal dye infusion without a lumbar puncture. CSF pressure at the cisterna magna was recorded throughout the procedure. No significant differences in the leakage indicators were found between the fibrin glue-injected and sham-operated group, whereas both groups showed significant differences with respect to the control group. The fibrin glue seal was effective against CSF pressures of 24.5 [17-31] cm H(2)O. We conclude that percutaneously injected fibrin glue is effective in stopping CSF leaks after dural puncture in this animal model. IMPLICATIONS: In this swine study, we repaired a cerebrospinal fluid leak after a dural puncture by percutaneously injecting tissue adhesive. The technique of percutaneous injection of fibrin glue seems promising for the prophylaxis of headache associated with cerebrospinal fluid leakage, and may be an alternative to an epidural blood patch.

Animals↗
PubMed2001

Acute hemorrhagic complication of diagnostic lumbar puncture.

OBJECTIVE: To present a case of an epidural hematoma after lumbar puncture in a pediatric patient without known risk factors for such a complication and to review the literature regarding this complication. DESIGN: Case report, review of the literature, and discussion. DATA SOURCES: A review of MEDLINE (1966-1998) for keywords "lumbar puncture" and "hemorrhage" or "hematoma" was conducted, and each bibliography was reviewed for other sources extending to 1911. Articles describing a case of spinal hematoma after a lumbar puncture for any procedure were included. RESULTS: A 5-year-old boy underwent a lumbar puncture for evaluation of lethargy and fever, and subsequently developed marked back pain and severe pain on flexion of his legs. Magnetic resonance imaging revealed an epidural blood collection. The patient's symptoms resolved over the next few days in association with steroid administration. Multiple reports of epidural and subdural hematomas were found on literature review, most occurring in the setting of coagulation abnormalities. These reports involve lumbar puncture in anesthetic, interventional, and diagnostic settings. CONCLUSION: Lumbar puncture is a frequently employed procedure. Known complications include epidural, subdural, and subarachnoid hemorrhage, usually in the setting of abnormal coagulation. The case presented is unusual in that the patient is a child and lacks any known risk factors for a hemorrhagic complication. Such a complication appears to be rare; only five of the 64 cases discovered in the literature review occurred following this diagnostic procedure in patients without known risk factors.

Acute Disease↗
PubMed2006

Anchoring of the internal jugular vein with a pilot needle to facilitate its puncture with a wide bore needle: a randomised, prospective, clinical study.

In this prospective, randomised study, consented adult patients of both genders were divided into two groups. In group 1 (n = 79) patients, during internal jugular vein cannulation, the pilot needle was removed before the wide bore needle (18G) puncture. In group 2 (n = 78) patients, the internal jugular vein was anchored by leaving the pilot needle in place during wide bore needle puncture. In demographically similar groups, the first attempt success rate improved from 64% in group 1 to 81% in group 2 (p < 0.05). Internal jugular vein puncture was more frequently detected at the entry of the needle with anchoring (group 2: 78%) than without (group 1: 53%); p < 0.05. Ultrasonography of a further 30 internal jugular vein punctures in each group demonstrated that the anchoring manoeuvre (group 2b) significantly (p < 0.05) prevented an indenting effect of the puncture needle, with a higher vertical to horizontal diameter ratio of the internal jugular vein when there was anchoring (0.97; SD 0.004) than without pilot needle anchoring (0.65; SD 0.008). In conclusion, when using surface landmarks, anchoring of the internal jugular vein with the pilot needle facilitated its puncture.

Adult↗