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PubMed1996

Anesthetic efficacy of eutectic prilocaine-lidocaine cream in pediatric oncology patients undergoing lumbar puncture.

OBJECTIVE: To evaluate the efficacy of eutectic mixture of local anesthetics 5% (Emla) in reducing pain associated with lumbar punctures in children. DESIGN: Prospective, double-blind, randomized, placebo-controlled trial. SETTING: University pediatric hospital. PATIENTS: Eleven pediatric oncology patients (mean age 6.6 y, range 4-16) who underwent 31 lumbar punctures. MAIN OUTCOME MEASURES: The analgesic effect was measured by using two methods. The first was a 10-point visual analog scale reported by the patient and the second was an 8-point behavioral pain scale assessed by the nurse who applied the cream. RESULTS: Emla cream was associated with significantly lower pain scores than those with placebo as measured by the patient when the puncture was successful on the first attempt (2.0 +/- 1.6 Emla group, 3.8 +/- 1.9 placebo group; p < 0.05). CONCLUSIONS: The use of Emla cream may reduce pain substantially only in patients who undergo a successful lumbar puncture on the first attempt.

Adolescent↗
PubMed2005

Efficacy of the epidural blood patch for the treatment of post lumbar puncture headache BLOPP: a randomised, observer-blind, controlled clinical trial [ISRCTN 71598245].

BACKGROUND: Post dural punction headache (PDPH) occurs in 10% to 40% of the patients who had a lumbar puncture. Its symptoms can be severe and incapacitating. The epidural blood patch is widely accepted as the treatment of choice for postdural puncture headache. Uncontrolled studies report rapid recovery after patching in 90% to 100% of treated patients. However, sufficient evidence from randomised, controlled clinical trials is lacking. METHODS: BLOPP (blood patch for post dural puncture headache) is a randomised, single centre, observer-blind clinical trial. Patients with PDPH for at least 24 hours and at most 7 days after lumbar puncture will be randomised to treatment with an epidural blood patch (EDBP) or to conventional treatment, i.e. 24 hours bed rest and ample fluid intake. PDPH 24 hours after treatment, classified on a 4-point scale (no, mild, moderate, severe) is the primary outcome. The secondary outcome is the presence of PDPH 7 days after treatment. We estimated that a sample size of 2 x 20 patients would provide us with a power of 80% to detect a relative reduction in number of patients with persisting PDPH after 24 hours of 50% at the usual significance level alpha = 5%, taking into account that in approximately 10% of the patients the PDPH will have resolved spontaneously after one day. DISCUSSION: The EDBP is accepted as the treatment of choice for PDPH although randomised, controlled data is scarce. Our randomised, observer-blind clinical trial enables us to compare the efficacy of two clinically practiced methods of PDPH treatment; EDBP versus conventional treatment, as they are applied in clinical practise.

Adolescent↗
PubMed2006

Intracranial pressure monitoring and lumbar puncture after endoscopic third ventriculostomy in children.

OBJECTIVE: The aim of this study is to analyze changes in intracranial pressure (ICP) after endoscopic third ventriculostomy (ETV) performed in children affected by noncommunicating hydrocephalus. METHODS: ICP was continuously recorded for an average of 7 days in 64 children who underwent 68 ETVs for obstructive triventricular hydrocephalus of various etiology. In the first group (44 children), ETV was performed as the primary treatment; in the second group (20 children), the patients presented with shunt malfunction and underwent ETV and shunt removal. Three of the patients in the second group were reoperated for obstruction of the stoma: two were reoperated once and one was reoperated twice. RESULTS: ICP changes after ETV were not homogeneous and varied according to etiology: the highest values were observed in patients affected by posterior fossa tumors and the lowest values were seen in patients operated on during shunt malfunction and who had their shunt removed. After 31 procedures (45.6%), ICP remained normal (< 20 mmHg) for the entire duration of the monitoring. After 37 procedures (54.5%), ICP was persistently high on Day 1 (mean, 29.7) and decreased very slowly in the subsequent days, remaining high for 2-9 days (mean, 4.5). After 20 of the 37 procedures with high postoperative ICP, patients presented symptoms of intracranial hypertension that resolved, in most of the cases, with one or two lumbar punctures. Lumbar puncture was noted to be effective in bringing about fast normalization of the ICP and resolution of the symptoms. In 13 patients (19.1%), ETV failed and a ventriculoperitoneal shunt was implanted. After four procedures, the stoma obstructed and the patients were treated, reopening the stoma. Postoperative ICP was not statistically significant higher in the patients in whom ETV failed. CONCLUSION: The high ICP observed in a group of patients in the early postoperative days is probably related to the slow permeation of the subarachnoid spaces by the cerebrospinal fluid flowing out of the third ventriculostomy. Management of intracranial hypertension after ETV remains a matter of controversy. The role of the lumbar puncture in the faster normalization of the ICP is examined in this article. By increasing the compliance and the buffering capacities of the spinal subarachnoid spaces, it probably decreases the cerebrospinal fluid outflow resistance from the ventricular system, facilitating the decrease of the ventricular volume and allowing faster permeation of the intracranial subarachnoid spaces. High postoperative ICP can account for persistent symptoms of intracranial hypertension and ventricular dilatation on computed tomographic scans after third ventriculostomy. A cycle of one to three lumbar punctures should always be performed in patients who remain symptomatic and who show increasing ventricular dilatation after ETV, before ETV is assumed to have failed and an extracranial cerebrospinal fluid shunt is implanted.

Cerebrospinal Fluid Shunts↗
PubMed1990

Percutaneous femoral artery puncture: practice and anatomy.

In a survey of the superficial landmarks used to select the site of puncture of the femoral artery for angiography, the inguinal skin crease was most popular, preferred by 39.2% of angiographers. The maximal femoral pulse irrespective of the position of the skin crease was the next most popular landmark (24.7%). Bony landmarks were least popular (13.0%). The majority (73.7%) of those using the skin crease punctured at the same level or distal to it. The relationship of these superficial landmarks to the common femoral artery (CFA) and its bifurcation were investigated. The inguinal skin crease was distal to the bifurcation of the CFA in 71.9% of limbs (mean, 0.61 cm). The maximal femoral pulse was over the CFA in 92.7% of limbs, and the CFA was projected over the medial aspect of the femoral head in 77.9% of limbs. The use of the inguinal skin crease is a popular though unreliable guide for puncture of the CFA. Use of the maximal femoral pulse will enable more constant puncture of the CFA.

Catheterization, Peripheral↗
PubMed2004

Headache and backache after lumbar puncture in children and adolescents: a prospective study.

OBJECTIVE: After lumbar puncture, many adults develop headaches or backaches. Postpuncture complaints are believed to be rare in children and adolescents, but their exact incidence is unclear because there is a paucity of data derived from general pediatric patients. In a prospective study of general pediatric and neuropediatric patients, we investigated the frequency of postlumbar puncture headaches or backaches and factors that might influence their occurrence. METHODS: Conducted over 12 months, the prospective study included 112 patients aged 2 to 16 years. We evaluated them for factors that might influence the rate of postpuncture complaints: age, gender, use of local anesthesia, cannula gauge, bevel orientation, number of puncture attempts, volume of cerebrospinal fluid (CSF) aspirated, and cell count in CSF. RESULTS: Twenty-seven percent of the patients experienced headaches (positional headache in 9%), and 40% developed backache. Frequency of complaints increased in relation to patients' age. In older children, girls reported complaints more frequently than did boys. Patients with higher cell counts in CSF had more frequent headaches than did patients without pleocytosis. Cannula gauge or bevel orientation did not influence outcome. CONCLUSION: The frequency of positional and nonpositional headaches after lumbar puncture is lower in children than in adults. Backaches contribute significantly to postpuncture morbidity. With puberty, the incidences of postpuncture complaints increase, and girls start to become more prone to develop postpuncture headaches. Recommendations regarding cannula gauge or bevel orientation that derive from studies in adults are not confirmed for children.

Adolescent↗
PubMed2006

CT-guided transthoracic needle biopsy using a puncture site-down positioning technique.

OBJECTIVE: We have developed a new CT-guided technique using puncture site-down positioning during the biopsy. The goal of our study was to determine the efficacy and safety of this technique for biopsy of lung lesions compared with the standard technique. MATERIALS AND METHODS: Medical records of 236 patients who underwent CT-guided transthoracic needle biopsy were retrospectively evaluated. This study included 89 cases that were biopsied using the standard technique (group A) and 147 cases that were biopsied using the puncture site-down positioning technique (group B). A 20-gauge automated cutting needle without coaxial technique was used in all patients. Medical records were reviewed for lesion size and location, biopsy results, and complications. RESULTS: When using the standard technique, the sensitivity for malignant lesions was 96.1%; the sensitivity for benign lesions, 92.1%; and diagnostic accuracy, 94.4%. Thirty-seven patients (41.6%) had pneumothorax, with 16 (18.0%) requiring chest tube placement. When using the puncture site-down positioning technique, the sensitivity for malignant lesions was 95.4%; the sensitivity for benign lesions, 93.3%; and diagnostic accuracy, 94.6%. Nineteen patients (12.9%) had pneumothorax, with four (2.7%) requiring chest tube placement. Other complications were minimal. CONCLUSION: CT-guided transthoracic needle biopsy using the puncture site-down positioning technique is an effective and safe procedure with a high diagnostic accuracy and low complication rate. This new technique is especially useful in reducing the rate of pneumothorax.

Adult↗
PubMed1977

Renal cyst puncture and aspiration: a survey of complications.

Complications of cyst puncture and aspiration were analyzed in a survey of 5,674 cases reported by 84 institutions. The mean incidence of major complications was 1.4%. For institutions with extensive experience, the incidence of major complications was 0.75%. Minor complications occurred in probably 10% of all patients but were only detectable at institutions undertaking routine followup. Flexible and malleable equipment for puncture lessened the risk of major complications. Approach to lesions in the upper poles of the kidneys via an oblique pathway using fluoroscopic or ultrasound guidance decreased the risk of pneumothorax compared to direct introduction of the needle through the ultrasound transducer. The incidence of complications did not correlate with number of puncture attempts, gauge of puncture equipment utilized, or completeness of cyst evacuation.

Hemorrhage↗
PubMed1990

The posterior intercostal approach for percutaneous renal procedures: risk of puncturing the lung, spleen, and liver as determined by CT.

A posterior intercostal approach is commonly used for percutaneous access to the upper poles of the kidney. However, the safety of this approach with respect to puncturing the intervening lung, pleura, liver, and spleen with the needle has been inferred only from a small series of patients without regard to the degree of respiration. To determine the possibility of puncturing these structures, we performed CT at both maximal inspiration and expiration and with sagittal reconstructions in 43 (27 supine and 16 prone) randomly selected patients. With expiration, the needle path was such that there was little risk to the spleen and liver from an 11th-12th posterior intercostal approach. However, the chance of transgressing the lung with this approach to the kidney was 29% on the right and 14% on the left. If done during maximal inspiration, the lung would be in the path of the needle in most patients. With a 10th-11th rib posterior intercostal approach, the chance of puncturing the lung was excessive regardless of the degree of respiration used. Our results show that the primary risk from a posterior 11th-12th rib intercostal approach to the upper renal collecting system is puncture of intervening lung, a complication that can be expected to occur in from 14% to 29% of patients. The risks from a posterior 10th-11th rib intercostal approach appear prohibitive.

Adult↗
PubMed2003

Single-wall puncture: a new technique for percutaneous transhepatic biliary drainage.

OBJECTIVE: The purpose of our study is to evaluate the safety and utility of a new single-wall puncture technique for percutaneous transhepatic biliary drainage in comparison with the conventional double-wall puncture technique. CONCLUSION: Our results suggest that the single-wall puncture technique is a useful method for percutaneous transhepatic biliary drainage and may be safer than the conventional double-wall puncture technique.

Adult↗
PubMed1994

Significance of simple renal cysts and percutaneous cyst puncture on renal function.

Renal function was investigated in 17 patients with simple renal cysts. Single kidney glomerular filtration rate was estimated by gamma camera renography with 99mTc-DTPA before, 5 days and 6 months after percutaneous puncture and evacuation of the cysts. Prior to the puncture and evacuation, the only negative effects on renal function noted were signs of moderate obstruction of the renal outflow in 2 patients. Percutaneous puncture with evacuation of the cystic fluid did not change the renal function significantly. It was concluded that simple renal cysts do not have any functional consequences nor does percutaneous puncture and evacuation of the cysts.

Aged↗
PubMed1991

[Endourological re-establishment by transluminal puncture for a complete obliteration of traumatic urethral disruption].

We performed transluminal re-canalization by needle puncture under fluoro-endoscopic control on a total of ten patients (membranous urethra, 8; bulbous urethra, 2) with complete obliteration after traumatic urethral disruption. The re-canalized tract was created by balloon dilation, internal urethrotomy or endoscopic resection of the scar tissue. The patient age ranged from 10 to 57 years (mean age; 37.9 +/- 15.3 years). A transluminal puncture was attempted in three patients by transperineal-transurethral approach and in seven by transurethral approach. In one of them, who sustained a complete membranous disruption 5 weeks ago, transluminal puncture failed because of the movable proximal urethra. The remaining nine patients voided without difficulty for the mean follow-up period of 18.1 +/- 14.3 months (range: 2-46). Three patients had mild stress urinary incontinence. A transluminal puncture is less invasive, safe and reliable for re-establishment of the true proximal part of the disrupted urethra. It can be recommended as a useful technique for endo-urological re-establishment for a completely obliterated urethra. Although this endoscopic re-establishment requires urethral sounding or internal urethrotomy for 6 months postoperatively, it may be an alternative to conventional surgical repair.

Adolescent↗
PubMed2000

Traumatic lumbar puncture at diagnosis adversely affects outcome in childhood acute lymphoblastic leukemia.

The effect of traumatic lumbar puncture at the time of initial diagnostic workup on treatment outcome in children with newly diagnosed acute lymphoblastic leukemia (ALL) was investigated. The findings of the first 2 lumbar punctures performed on 546 patients with newly diagnosed ALL treated on 2 consecutive front-line studies (1984-1991) at St Jude Children's Research Hospital were retrospectively reviewed. Lumbar punctures were performed at the time of diagnosis and again for the instillation of first intrathecal chemotherapy. The event-free survival (EFS) experience for patients with 1 cerebrospinal fluid (CSF) sample contaminated with blast cells was worse than that for patients with no contaminated CSF samples (P =.026); that of patients with 2 consecutive contaminated CSF samples was particularly poor (5-year EFS = 46 +/- 9%). In a Cox multiple regression analysis, the strongest prognostic indicator was 2 consecutive contaminated CSF samples, with a hazard ratio of 2.39 (95% confidence interval, 1. 36-4.20). These data indicate that contamination of CSF with circulating leukemic blast cells during diagnostic lumbar puncture can adversely affect the treatment outcome of children with ALL and is an indication to intensify intrathecal therapy.

Adolescent↗
PubMed1999

[Post lumbar puncture syndrome and the manner of needle insertion].

We have analysed the correlation between the direction of needle bevel insertion and the occurrence of post-puncture syndrome appearing after diagnostic lumbar puncture. Post-puncture headache was observed in 38 of 380 patients (13.6%). The syndrome occurred in 11 patients (7.9%) in whom the needle bevel had been inserted parallel to the patient's backbone and in 27 patients (19.3%) in whom the needle bevel had been inserted perpendicularly to the backbone. The complications after lumbar puncture could be reduced by inserting the needle bevel parallel to the patient's backbone.

Adult↗
PubMed2001

Prediction of bacterial meningitis in children with meningeal signs: reduction of lumbar punctures.

UNLABELLED: Physicians often have to perform a lumbar puncture to ascertain the diagnosis in patients with meningeal signs, because of the serious consequences of missing bacterial meningitis. The aim of this study was to derive and validate a clinical rule to predict bacterial meningitis in children with meningeal signs, to guide decisions on the performance of lumbar punctures. Information was collected from records of patients (aged 1 mo to 15 y) consulting the emergency department of the Sophia Children's Hospital between 1988 and 1998 with meningeal signs. Bacterial meningitis was defined as cerebrospinal fluid (CSF) leucocyte count >5 cells microl(-1) with a positive bacterial culture of CSF or blood. The diagnostic value of predictors was judged using multivariate logistic modelling and area under the receiver operating characteristic curves (ROC area). In the derivation set (286 patients, years 1988-1995) the duration of the main complaint, vomiting, meningeal irritation, cyanosis, petechiae and disturbed consciousness were independent clinical predictors of bacterial meningitis. The ROC area of this model was 0.92. The only independent predictor from subsequent laboratory tests was the serum C-reactive protein concentration, increasing the ROC area to 0.95. Without missing a single case, this final model identified 99 patients (35%) without bacterial meningitis. Validation on 74 consecutive patients in 3 subsequent years (1996-1998) yielded similar results. CONCLUSION: This prediction rule identifies about 35% of the patients with meningeal signs in whom a lumbar puncture can be withheld without missing a single case of bacterial meningitis. For the individual patient this prediction rule is valuable in deciding whether or not to perform a lumbar puncture.

Blood↗
PubMed2001

Combined fourth and sixth cranial nerve palsy after lumbar puncture: a rare complication. A case report.

Palsies of cranial nerves are well-known complications after lumbar puncture. Sixth nerve palsies are the most common. They normally occur 4 to 14 days after the lumbar puncture and spontaneously recover in a few weeks or months. The occurrence of a fourth nerve palsy following lumbar puncture however is extremely rare. We report on a patient who developed a combined contralateral fourth and sixth nerve palsy after lumbar puncture (Syndrome of Intracranial Hypotension), requiring surgical correction for secondary diplopia.

Abducens Nerve Diseases↗
PubMed2001

Reducing bedrest following arterial puncture for coronary interventional procedures--impact on vascular complications: the BAC Trial.

BACKGROUND: The optimal time for ambulating patients following femoral arterial puncture for percutaneous coronary intervention is unknown. This study was designed to test the hypothesis that reducing time to ambulation from 6 hours to 2 hours would not increase vascular complications. METHODS: In this randomized, controlled, single-center trial, patients were randomly assigned to receive either 2, 4 or 6 hours (control group) of bedrest after hemostasis was achieved at the femoral arterial puncture site. A total of 354 patients, enrolled from March 1997 to October 1998, participated in the study with 299 completing the full protocol. The primary endpoint was the incidence of vascular complications and any resulting interventions or outcomes including surgery, blood transfusion, prolonged length of stay or ultrasound compression. RESULTS: The 2 hour and 4 hour experimental groups were comprised of 99 patients each, while the 6 hour control group was comprised of 101 patients. There were no differences in vascular complications between the groups. A subgroup analysis of patients who received abciximab (n = 43) did not reveal any differences between groups. Only one patient developed a pseudoaneurysm (p = 0.36), requiring surgical repair and a prolonged length of stay. CONCLUSIONS: Patients undergoing femoral arterial puncture for coronary interventional procedures can safely ambulate 2 hours after hemostasis of the puncture site. Patients receiving abciximab as part of their coronary procedure may be able to ambulate as early as 2 hours following hemostasis.

Adult↗
PubMed2001

Effect of amniotic sac puncture on parturition in rat.

Pregnant Charles Foster rats were subjected to amniotic sac puncture on day 15 of gestation and the effect was observed on parturition. All the control rats as expected delivered on day 22 of gestation. In the group where all the sacs were punctured, only 12.5% rats delivered on day 22 while rest either failed to deliver (62.5%) or died (25%). In the group with unpunctured sacs at vaginal ends, 75% rats delivered on day 21 while 25% on day 22. In the group with unpunctured sacs at ovarian ends, 75% rats delivered on day 23 and rest 25% failed to deliver. The resorption rates ranged between 61 to 94% in different groups. Malformations were observed only in one pup. The results suggest that amniotic sac puncture interferes with parturition in the form of either failure or delayed parturition. Nonpatency of the birth canal due to puncture induced fetal deaths and tissue adhesions were presumed to be the contributing factors.

Amniocentesis↗
PubMed1975

Spreading depression resulting from cortical punctures.

In acute experiments on cats under deep Nembutal anesthesia punctures of the cortex caused a prolonged negative shift of its surface potential (up to 15 mv, 5.5 min), which was followed by a prolonged positive shift. During these shifts of the potential, both components of the direct response were depressed. The changes in potential and the depression of electric activity spread over the cortex at a mean rate of 65 micrometers/s. The phenomenon arised when the punctures are made with a pipet 20 micrometers and above in diameter. A puncture of the surface structures was critical; passage of the pipet through the middle and deep layers was ineffective. It is assumed that when cortical punctures are made the SD is caused by K(+) ions which leak out of the destroyed glial structures.

Animals↗