Intraspinal and intracranial hemorrhage after lumbar puncture

Feasibility of ultrasound-assisted lumbar punctures performed by pediatric oncologists at the point of care

BACKGROUND

Ultrasound assistance improves success rates and reduces adverse outcomes of lumbar punctures (LPs) among adult patients in the emergency room and the operating room, but has not been evaluated in pediatric patients with cancer. Our objectives were (1) to determine whether pediatric oncologists could perform ultrasound-assisted LPs following a structured teaching curriculum, and (2) to determine the feasibility of recruiting pediatric cancer patients to a clinical trial of this procedure.

METHODS

Three pediatric oncologists completed a curriculum composed of didactic teaching followed by hands-on workshops. Each learner was evaluated during 20 attempts at three ultrasound tasks using the cumulative sum method. The three pediatric oncologists then performed ultrasound assessments prior to routinely scheduled LPs. Feasibility was defined as ability to perform at least 30 ultrasound-assisted LPs within 6 months. Secondary outcomes were the proportion of successful, bloody, or traumatic LPs, time required, and perceived helpfulness of ultrasound.

RESULTS

All three pediatric oncologists achieved competence in the three tasks of ultrasound scanning within 20 evaluated attempts. We recruited 62 patients within 1 month, and 58 underwent an ultrasound-assisted LP. All LPs were successful. Two LPs (4%) had ≥500 red blood cells (RBCs)/μl, and nine (16%) had ≥10 RBCs/μl. Median time to conduct the scan was 1.9 minutes (range 0.8-4.0 minutes). In 37 (64%) of the LPs, ultrasound assistance was considered helpful or very helpful.

CONCLUSIONS

Pediatric oncologists readily achieved competence in ultrasound-assisted LPs, and ultrasound was commonly perceived as helpful. It is feasible to proceed to a randomized trial of this procedure in pediatric cancer.

Consensus statement on abusive head trauma in infants and young children

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.

Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia

BACKGROUND

People with a low platelet count (thrombocytopenia) often require lumbar punctures or an epidural anaesthetic. Lumbar punctures can be diagnostic (haematological malignancies, subarachnoid haematoma, meningitis) or therapeutic (spinal anaesthetic, administration of chemotherapy). Epidural catheters are placed for administration of epidural anaesthetic. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to lumbar punctures and epidural anaesthesia, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to these procedures varies significantly from country to country. This indicates significant uncertainty among clinicians regarding the correct management of these patients. The risk of bleeding appears to be low, but if bleeding occurs it can be very serious (spinal haematoma). Consequently, people may be exposed to the risks of a platelet transfusion without any obvious clinical benefit.This is an update of a Cochrane Review first published in 2016.

OBJECTIVES

To assess the effects of different platelet transfusion thresholds prior to a lumbar puncture or epidural anaesthesia in people with thrombocytopenia (low platelet count).

SEARCH METHODS

We searched for randomised controlled trials (RCTs), non-randomised controlled trials (nRCTs), controlled before-after studies (CBAs), interrupted time series studies (ITSs), and cohort studies in CENTRAL (the Cochrane Library 2018, Issue 1), MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 13 February 2018.

SELECTION CRITERIA

We included RCTs, nRCTs, CBAs, ITSs, and cohort studies involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people of any age with thrombocytopenia requiring insertion of a lumbar puncture needle or epidural catheter.The original review only included RCTs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane for including RCTs, nRCTs, CBAs, and ITSs. Two review authors independently assessed studies for eligibility and risk of bias and extracted data. Results were only expressed narratively.

MAIN RESULTS

We identified no completed or ongoing RCTs, nRCTs, CBAs, or ITSs. No studies included people undergoing an epidural procedure. No studies compared different platelet count thresholds prior to a procedure.In this update we identified three retrospective cohort studies that contained participants who did and did not receive platelet transfusions prior to lumbar puncture procedures. All three studies were carried out in people with cancer, most of whom had a haematological malignancy. Two studies were in children, and one was in adults.The number of participants receiving platelet transfusions prior to the lumbar puncture procedures was not reported in one study. We therefore only summarised in a narrative form the relevant outcomes from two studies (150 participants; 129 children and 21 adults), in which the number of participants who received the transfusion was given.We judged the overall risk of bias for all reported outcomes for both studies as 'serious' based on the ROBINS-I tool.No procedure-related major bleeding occurred in the two studies that reported this outcome (2 studies, 150 participants, no cases, very low-quality evidence).There was no evidence of a difference in the risk of minor bleeding (traumatic tap) in participants who received platelet transfusions before a lumbar puncture and those who did not receive a platelet transfusion before the procedure (2 studies, 150 participants, very low-quality evidence). One of the 14 adults who received a platelet transfusion experienced minor bleeding (traumatic tap; defined as at least 500 x 10⁶/L red blood cells in the cerebrospinal fluid); none of the seven adults who did not receive a platelet transfusion experienced this event. Ten children experienced minor bleeding (traumatic taps; defined as at least 100 x 10⁶/L red blood cells in the cerebrospinal fluid), six out of the 57 children who received a platelet transfusion and four out of the 72 children who did not receive a platelet transfusion.No serious adverse events occurred in the one study that reported this outcome (1 study, 21 participants, very low-quality evidence).We found no studies that evaluated all-cause mortality within 30 days from the lumbar puncture procedure, length of hospital stay, proportion of participants who received platelet transfusions, or quality of life.

AUTHORS' CONCLUSIONS

We found no evidence from RCTs or non-randomised studies on which to base an assessment of the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter. There are no ongoing registered RCTs assessing the effects of different platelet transfusion thresholds prior to the insertion of a lumbar puncture or epidural anaesthesia in people with thrombocytopenia. Any future study would need to be very large to detect a difference in the risk of bleeding. A study would need to be designed with at least 47,030 participants to be able to detect an increase in the number of people who had major procedure-related bleeding from 1 in 1000 to 2 in 1000. The use of a central data collection register or routinely collected electronic records (big data) is likely to be the only method to systematically gather data relevant to this population.

Intracranial hemorrhage after spine surgery

OBJECT

The authors describe the largest case series of 8 patients with intracranial hemorrhage (ICH) after spinal surgery and identify associated pre-, intra-, and postoperative risk factors in relation to outcome.

METHODS

The authors retrospectively reviewed the cases of 8 patients treated over 16 years at a single institution and also reviewed the existing literature and collected demographic, treatment, and outcome information from 33 unique cases of remote ICH after spinal surgery.

RESULTS

The risk factors most correlated with ICH postoperatively were the presence of a CSF leak intraoperatively and the use of drains postoperatively with moderate hourly serosanguineous output in the early postoperative period.

CONCLUSIONS

Intracranial hemorrhage is a rare complication of spinal surgery that is associated with CSF leakage and use of drains postoperatively, with moderate serosanguinous output. These associations do not justify a complete avoidance of drains in patients with CSF leakage but may guide the treating physician to keep in mind drain output and timing of drain removal, while noting any changes in neurological examination status in the meantime. Additionally, continued and worsening neurological symptoms after spinal surgery may warrant cranial imaging to rule out intracranial hemorrhage, usually within the first 24 hours after surgery. The presence of cerebellar hemorrhage and hydrocephalus indicated a trend toward worse outcome.

Intramedullary spinal cord abscess as complication of lumbar puncture: a case-based update

INTRODUCTION

Although lumbar puncture (LP) is a relatively straightforward procedure and is usually associated with low morbidity, rare and significant neurological complications can occur. Intramedullary spinal cord abscess (ISCA) after lumbar puncture is one of these serious complications; however, this complication has not yet been reported in children.

CASE REPORT

After 27 days in another medical facility, a 1-year-old girl was admitted to our hospital with a diagnosis of fever of unknown origin. Prior to the second admission, she had undergone multiple traumatic LP attempts. The patient was referred to our institution with progressive and ascending weakness. Three days later, this weakness involved all of the patient's four limbs. A LP was performed and showed purulent cerebrospinal fluid (CSF). An emergent spinal magnetic resonance imaging was performed and revealed an intramedullary lesion extending from the T2 to L3 level. Broad-spectrum antibiotics and steroids were administered to the patient, and a T2-L3 laminectomy was performed. The postoperative course was uneventful, but a neurologic deficit, including lower limb paralysis, remained.

CONCLUSION

The index of suspicion for a pyogenic infection of the intramedullary space should be higher if progressive flaccid paralysis develops within a few days after a lumbar procedure. Nevertheless, the diagnosis may be challenging due to the rarity of this condition. Any misdiagnosis or delay of adequate treatment may lead to unfavorable outcomes.

[Do paediatricians perform lumbar puncture correctly? Review of recommendations and analysis the technique in Spain]

INTRODUCTION

Lumbar puncture (LP) is a commonly performed procedure in paediatrics. Performing this technique properly can avoid the most common associated complications.

OBJECTIVE

To assess whether paediatricians and paediatric residents in Spain follow current recommendations for the LP technique.

MATERIAL AND METHODS

A cross-sectional study was conducted by sending a questionnaire by mail through the Spanish Society of Paediatric Emergencies, collecting demographic information and responses to multiple choice questions about LP technique.

RESULTS

A total of 206 questionnaires were analysed, of which 143 (69.5%) were answered by paediatricians, and 63 (30.5%) by paediatric residents. The majority (128; 62.1%) of physicians did not allow parents to be present during LP, 198 (96.1%) routinely use analgesia and sedation; 84 (42%) only used local anaesthesia. The majority of respondents used standard Quincke needles (126; 62.7%). The bevel was correctly positioned when puncturing the dura mater by 22 residents (36.1%) and 21 paediatricians (15.1%), a variation that was statistically significant (P=.001). For neonatal lumbar punctures, 63 paediatricians (46%) and 19 paediatric residents used a butterfly needle which did not contain a stylet, and this difference was also statistically significant (P=.035). Of those surveyed, 190 (92.2%) re-inserted the stylet when re-orientating the needle, and 186 (93%) re-oriented this when removing it. The recommendation of bed rest was made by 195 (94.7%) physicians.

CONCLUSIONS

The majority of paediatricians orient the bevel wrongly when inserting the needle during LP, and still use "butterfly" needles in newborns, despite warnings to the contrary. Paediatric residents and less experienced paediatricians follow the recommendations more frequently.

Subdural hematoma in infants: can it occur spontaneously? Data from a prospective series and critical review of the literature

BACKGROUND

Subdural hematomas (SDH) in infants often result from nonaccidental head injury (NAHI), which is diagnosed based on the absence of history of trauma and the presence of associated lesions. When these are lacking, the possibility of spontaneous SDH in infant (SSDHI) is raised, but this entity is hotly debated; in particular, the lack of positive diagnostic criteria has hampered its recognition. The role of arachnoidomegaly, idiopathic macrocephaly, and dehydration in the pathogenesis of SSDHI is also much discussed.

PURPOSE

We decided to analyze apparent cases of SSDHI from our prospective databank.

MATERIALS AND METHODS

We selected cases of SDH in infants without systemic disease, history of trauma, and suspicion of NAHI. All cases had fundoscopy and were evaluated for possible NAHI. Head growth curves were reconstructed in order to differentiate idiopathic from symptomatic macrocrania.

RESULTS

Sixteen patients, 14 males and two females, were diagnosed with SSDHI. Twelve patients had idiopathic macrocrania, seven of these being previously diagnosed with arachnoidomegaly on imaging. Five had risk factors for dehydration, including two with severe enteritis. Two patients had mild or moderate retinal hemorrhage, considered not indicative of NAHI. Thirteen patients underwent cerebrospinal fluid drainage. The outcome was favorable in almost all cases; one child has sequels, which were attributable to obstetrical difficulties.

CONCLUSION

SSDHI exists but is rare and cannot be diagnosed unless NAHI has been questioned thoroughly. The absence of traumatic features is not sufficient, and positive elements like macrocrania, arachnoidomegaly, or severe dehydration are necessary for the diagnosis of SSDHI.

Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia

One of the prices paid for chemo- and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three-part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems-based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.

Anesthetic considerations for the pediatric oncology patient--part 1: a review of antitumor therapy

The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should possess a basic understanding of cancer treatment. While this is an ever-changing field, a basic knowledge of chemotherapeutic drugs, radiation therapy, and the toxicities of each is necessary to prepare a safe anesthetic plan. Such an understanding also assists the anesthesiologist as the perioperative specialist for these children in consultation with the surgeon and oncologist. This article, which is the first of a three-part review series, will review current principles of cancer therapy and the general mechanisms of toxicity to the child. Although this article is not intended to comprehensively review the fundamentals of chemotherapy and radiation therapy, the consequences of anticancer therapy that impact perioperative care and decision making are presented for the anesthesiologist.