Lumbar puncture success rate is not influenced by family-member presence

Physician's conceptions of the decision-making process when managing febrile infants ≤ 60 days old: a phenomenographic qualitative study

BACKGROUND

The management of febrile infants aged ≤ 60 days and adherence to guidelines vary greatly. Our objective was to describe the process of decision-making when managing febrile infants aged ≤ 60 days and to describe the factors that influenced this decision.

METHODS

We conducted 6 focus group discussions with 19 clinically active physicians in the pediatric emergency departments of 2 university hospitals in Skåne region, Sweden. We followed an inductive qualitative design, using a phenomenological approach. A second-order perspective was used, focusing on how physicians perceived the phenomenon (managing fever in infants) rather than the phenomenon itself. The transcribed interviews were analyzed using a 7-step approach.

RESULTS

Performing a lumbar puncture (LP) was conceived as a complex, emotionally and mentally laden procedure and dominated the group discussions. Three central categories emerged as factors that influenced the decision-making process on whether to perform an LP: 1) a possible focus of infection that could explain the origin of the fever, 2) questioning whether the temperature at home reported by the parents was a fever, especially if it was ≤ 38.2°C, and 3) the infant's general condition and questioning the need for LP in case of well-appearing infants. Around these 3 central categories evolved 6 secondary categories that influenced the decision-making process of whether to perform an LP or not: 1) the physicians' desire to be able to trust their judgement, 2) fearing the risk of failure, 3) avoiding burdensome work, 4) taking others into account, 5) balancing guidelines and resources, and 6) seeing a need to practice and learn to perform LP.

CONCLUSIONS

The difficulty and emotional load of performing an LP were important factors that influenced the decision-making process regarding whether to perform an LP. Physicians highlighted the importance of being able to rely on their clinical judgment and make independent decisions. Guidelines may consider allowing a degree of flexibility and independent thinking to take into account patients' characteristics and needs.

Lumbar puncture position in infants-a systematic review and meta-analysis

To analyze the optimal lumbar puncture position in infants. A systematic review and meta-analysis. Infants (age < 1 year). December 2022 in PubMed, Scopus, and Web of Science. Randomized controlled trials focusing on lumbar puncture positions were included. Other lumbar puncture position than standard lateral decubitus position. First puncture success and overall success rate. Secondary outcome was desaturation during puncture and procedure-related harms. Risk of bias 2.0 assessment was performed. Outcomes are reported as risk ratios (RR) with 95% confidence intervals (CI). We screened 225 abstracts, and six studies were included. Four studies compared sitting position, one study head elevated lateral position, and one study prone position to lateral position. Risk of bias was high in two studies. First puncture success rate in sitting position (RR 1.00, CI: 0.78-1.18; 2 studies) and overall success rate in sitting position were similar to lateral position (RR 0.97, CI: 0.87-1.17; 3 studies). First attempt success rate was higher in elevated lateral position (RR 1.48, CI: 1.14-1.92; 1 study) and in prone position (RR 1.09, CI: 1.00-1.17; 1 study).  Conclusion: Sitting position seems to be equally effective in terms of first attempt and overall success in lumbar puncture than standard lateral position. Elevated lateral position and prone positions had better first attempt success than standard lateral position, but these were assessed only in one study each and thus further studies in these positions are needed.  Trial registration: This review was registered in PROSPERO. ID: CRD42022382953. What is Known: •  Success rate in lumbar puncture has been poor and first attempt success rate has varied between 50 to 80% in literature. •  Optimal lumbar puncture positions for infants have been debated between sitting and lateral decubitus position mostly. What is New: •  This is the first meta-analysis focused on lumbar puncture positions in infants, and it found that sitting position was equal to standard lateral position. • Prone position and head elevated lateral positions had higher first puncture success rates, but these were assessed both only in one study, which creates uncertainty to the finding.

Stress: A Factor Explaining the Gap Between Simulated and Clinical Procedure Success

BACKGROUND

Stress may impair the success of procedures in emergency medicine. The aims were to assess residents' stress during simulated and clinical lumbar punctures (LPs) and to explore the correlation of stress and performance.

METHODS

A prospective study (2013-2016) was carried out in a pediatric emergency department. A mastery training and subsequently a just-in-time training were conducted immediately preceding each clinical LP. Stress was self-assessed by the Stress-O-Meter scale (0-10). Performance (checklist 0-6 points) and success rate (cerebrospinal fluid with <1000 red blood cells/mm3) were recorded by a trained supervisor. A survey explored self-confidence and potential causes of stress.

RESULTS

Thirty-three residents performed 35 LPs. There was no stress during simulation procedure. Stress levels significantly increased for clinical procedure (P < 0.0001). Performance was similar in simulation and in clinic (respectively, 5.50 ± 0.93 vs 5.42 ± 0.83; P = 0.75). Success significantly decreased during clinical LP (P < 0.0001). The 2 most reported stress-related factors were fear of technical errors and personal fatigue.

CONCLUSIONS

Performance scores and success rates in simulation are insufficient to predict success in clinical situations. Stress level and stress-related factors (fear of technical errors and personal fatigue) might be different in simulated or real conditions and consequently impact success of a technical procedure even if a high-performance score is recorded.

Real-time detection of cerebrospinal fluid with bioimpedance needle in paediatric lumbar puncture

Background

Lumbar puncture is a common clinical procedure that can occasionally be difficult. Various needle guidance methods can facilitate performing this procedure, but at the expense of special expertise, equipment and facility. In the present study, we evaluated the clinical feasibility of a novel bioimpedance needle system regarding its ability to detect cerebrospinal fluid (CSF) in paediatric lumbar punctures.

Methods

We performed 40 lumbar puncture procedures using the bioimpedance needle system in 37 paediatric patients, aged from 0 days to 17 months, as a part of their prescribed examinations in two university hospitals. The bioimpedance needle is similar to a conventional 22G cutting‐edge spinal needle with a stylet, except the needle and stylet are configured as a bipolar electrode with high spatial resolution. The system measures in real‐time when the needle tip reaches the subarachnoid space containing CSF. The procedure was considered successful when the erythrocyte count was determined from the obtained CSF sample.

Results

Subarachnoid space was verifiably reached in 28 out of 40 procedures (70%). Bioimpedance needle system detected CSF in 23 out of these 28 successful procedures (82%) while failed in 3 out of 28 procedures (11%). No adverse events were reported.

Conclusion

Bioimpedance spinal needle system was found clinically feasible in paediatric lumbar punctures, and it may offer an objective and simple means to detect the time point when the needle tip is in contact with the cerebrospinal fluid.

Paediatric lumbar punctures: How do paediatric and emergency doctors differ?

OBJECTIVE

The objective of the study was to identify any differences between emergency physicians and emergency trainees and paediatricians and paediatric trainees in performing paediatric lumbar punctures (LPs).

METHODS

Anonymous cross-sectional electronic survey was distributed to emergency physicians, emergency trainees, paediatricians and paediatric trainees within three hospitals of a single public health network. There were four standardised clinical scenarios (neonate, infant, young child and adolescent), with accompanying questions relating to neurological evaluation and imaging prior to LP, the use of written consent forms and parental presence during the procedure.

RESULTS

Paediatricians and paediatric trainees have greater confidence performing LP on neonates and infants, while emergency physicians and emergency trainees are more confident in older children. The only differences in self-reported neurological examination prior to LP was paediatricians and paediatric trainees being more likely to perform fundoscopy than were emergency physicians and emergency trainees in infants (21% vs 8%, P = 0.03) and young children (44% vs 16%, P < 0.001). Less than half of both groups of doctors would obtain written consent for paediatric LPs. Emergency physicians and emergency trainees were much more likely to encourage parents to remain in the room during the procedure than their paediatric counterparts (95% vs 37%, P < 0.0001).

CONCLUSION

Paediatricians and paediatric trainees are more likely to be confident in performing LP in very young children than are emergency physicians and emergency trainees. They are more likely to perform fundoscopy prior to the procedure, but are much less likely to encourage parental presence during the LP.

A randomised controlled trial of student nurse performance of cardiopulmonary resuscitation in a simulated family-witnessed resuscitation scenario

This randomized controlled trial, conducted in a UK University nursing department, compared student nurses' performance during a simulated cardiac arrest. Eighteen teams of four students were randomly assigned to one of three scenarios: 1) no family witness; 2) a "quiet" family witness; and 3) a family witness displaying overt anxiety and distress. Each group was assessed by observers for a range of performance outcomes (e.g. calling for help, timing to starting cardiopulmonary resuscitation), and simulation manikin data on the depth and timing of three cycles of compressions. Groups without a distressed family member present performed better in the early part of the basic life support algorithm. Approximately a third of compressions assessed were of appropriate pressure. Groups with a distressed family member present were more likely to perform compressions with low pressure. Groups with no family member present were more likely to perform compressions with too much pressure. Timing of compressions was better when there was no family member present. Family presence appears to have an effect on subjectively and objectively measured performance. Further study is required to see how these findings translate into the registered nurse population, and how experience and education modify the impact of family member presence.

An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond

BACKGROUND

Painful procedures are common in the ED setting and beyond. Although these procedures are often essential to patient management, they can also be distressing for children, parents, and health providers. As such, it is imperative that effective pain and anxiety-minimizing strategies be used consistently in all settings where painful procedures take place for children.

OBJECTIVES

This review article aims to provide a summary of several strategies, which are supported by definitive and systematically reviewed evidence, that can be implemented alone or in combination to reduce procedural pain and anxiety for children in the ED and beyond.

RESULTS

For neonates, breastfeeding, nonnutritive sucking, swaddling, and sucrose administration have all been shown to decrease pain during painful interventions. For neonates, venipuncture is much less painful than heel lance for blood draws. For infants, there is some support for sucrose use. For infants and older children, there is strong evidence for distraction techniques. In addition, the use of fast-acting topical anesthetic creams as an alternative or adjunct to infiltrating anesthetic before laceration repair or vascular access/venipuncture is recommended. Further, buffering of lidocaine can decrease pain during injection. Lastly, if a laceration is amenable to the use of tissue adhesive, this should be preferentially used.

CONCLUSIONS

In summary, there currently remains a knowledge-to-practice gap in the treatment of children's procedure-related pain. This article has identified multiple age-specific methods to improve the treatment of procedural pain. These simple interventions can improve the care provided to ill and injured children.

Emergency department companions of stroke patients: implications on quality of care

Acute care of stroke victims largely relies on the rapid identification and timely clinical and radiological assessment. We evaluated the effect of the number of patient companions on the efficiency of the diagnostic process in the emergency department (ED).Consecutive stroke patients admitted to the ED between August 2011 and October 2012 were evaluated. Clinical, epidemiological, and timeline data (symptoms onset, ED arrival, computed tomography [CT] scanning, and recombinant tissue plasminogen activator infusion), as well as the number of accompanying persons in the ED were prospectively recorded. We used multivariate Poisson log linear models to analyze the association of number of companions adjusted and door-to-CT times and logistic regression for the analysis of the successful identification of stroke patient by ED triage nurse.Out of a total of 724 stroke patients admitted, data regarding number of ED companions were available for 610 (84.3%) patients. Number of companions was associated with higher National Institute of Health Stroke Scale and speech disturbances. It was found to be independently associated with shorter time to CT scanning adjusted for the stroke severity, sex, and speech disturbances (no companions as a reference group, relative risks 0.82, 0.73, and 0.70 for 1, 2, and ≥3 companions, respectively, all P < 0.001). Similarly, number of companions was associated with higher rates of stroke recognition by the triage nurse adjusted for covariates (odds ratios 2.11, 2.62, and 4.11, respectively, all P < 0.05).Our findings suggest that the family members and other companions could serve as facilitators of faster and more effective ED management of stroke patients, possibly improving their outcome.

Observational study of family member presence for pediatric emergency department procedures

OBJECTIVE

The aim of this study was to observe the proportion of family members who choose to remain present during children's pediatric emergency department procedures in actual clinical situations.

METHODS

Family members of a convenience sample of children undergoing invasive procedures in a pediatric emergency department were observed. Data were collected on whether family members chose to remain present or leave during the procedure and family member and health care worker behaviors. Consent to participate in the study was obtained after the observation, and family members were surveyed regarding demographics, anxiety, and previous experiences.

RESULTS

Fifty-nine children undergoing 66 procedures and accompanied by 83 family members were enrolled. The median age of the children was 69 months; 47% were female and 73% were Hispanic. The family members consisted of 64% mothers and 24% fathers, with a median age of 33 years. The most common procedures were vascular access (25), laceration repair (11), and urethral catheterization (9). Overall, 73% of the family members stayed during the child's procedure, 18% left, and 9% showed some mixture of staying and leaving. Health care workers asked the family members to leave twice, encouraged them to leave once, and used nonverbal cues to exclude the family members twice. Caregivers helped to restrain the child 35% of the time.

CONCLUSIONS

Family members remain present during actual children's emergency department procedures less often than they indicate they would in hypothetical scenario surveys.

[Has the presence of parents during invasive procedures in the emergency department increased in the last few years?]

INTRODUCTION

In the recent years, parents are playing an important role in Pediatric Emergency Department (PED), and wish to be present when invasive procedures (IP) are performed.

OBJECTIVES

1) To compare the presence of parents during IP in PED in Spain between 2008 and 2012. 2) To compare the arguments to restrict the presence and problems arising from this, and 3) To determine whether the views of health personnel have changed on this subject.

METHODOLOGY

A descriptive multicenter comparative study was conducted in 2008 and 2012. A total of 42 questionaires were sent by email to PED managers, with the responding hospitals being included in the 2 periods of the study.

RESULTS

A total of 22 hospitals participated in the study. The presence of parents in the PED increased between 2008 and 2012 for all IP, significantly in the blood test and urine catheterization. In 2012, managers state that children are not so nervous, and anxiety of the parents and staff fear of a poorer performance, as an argument to restrict family presence. There were few problems during the 2 periods, with the poor behavior of the children decreasing. According to managers, the opinion of health personnel has not changed in the last four years.

CONCLUSIONS

The presence of parents during the IP in the PED has increased in the last four years, although the presence is low for more invasive procedures. Managers argue the presence of fewer behavior problems to restrict family presence. The opinion of the staff has not changed in the last four years, although more studies are required on this issue.

[Presence of family members while performing invasive procedures. A prospective study]

INTRODUCTION

Family members of child patients have traditionally not been allowed to be present during invasive procedures.

OBJECTIVES

To evaluate the level of satisfaction of family members, healthcare professionals, and the patients themselves, when family members are present during invasive procedures carried out in the pediatric emergency department.

MATERIALS AND METHODS

A prospective observational study was carried out, which included a questionnaire containing demographic information, the details of the procedure, and the level of satisfaction of the patient, their family members, and the healthcare professionals present.

RESULTS

Data was obtained from 75 procedures. In 5 of these, family members chose not to be present during the procedure. The most frequent procedures were lumbar punctures (44%), laceration repairs (22,7%) and venopunctures (17,3%). All (100%) the children who were asked wanted their family members to be present. 90% of family members and 57% of healthcare professionals were of the opinion that the presence of family members facilitated the procedure. Furthermore, 90% of family members and 76% of healthcare professionals thought that family presence was beneficial to the patient. 95% of family members and 71% of healthcare professionals thought that the option to be present during invasive procedures should be given to family members. 73% of healthcare professionals were satisfied with the presence of family members. On a scale of one to ten, overall satisfaction of family members was 9.5.

CONCLUSIONS

In our experience, family presence during invasive procedures is possible, and we have found this to be beneficial to the child. We also found that both family members and healthcare professionals were accepting and also satisfied with this new practice policy.

Family presence during invasive procedures at the emergency department: what is the opinion of Spanish medical staff?

OBJECTIVES

Family presence (FP) during invasive procedures (IPs) in children remains controversial among pediatric emergency department (PED) staff. The authors aimed to determine health care providers' attitudes toward FP during IPs in Spain, to learn whether parents are given the option of being present during different IPs, and to study which factors influence the providers' opinions.

METHODS

Observational study. Physicians and nurses were asked to answer a questionnaire, which was sent to 43 PEDs and was available at the Spanish Pediatric Emergency Society Web site.

RESULTS

We obtained 222 questionnaires from 36 Spanish hospitals. A total of 65.8% of the surveys were answered by physicians (66.4% pediatricians) and 34.2% by nurses. The median age of the respondents was 32 years, and 69.2% were women. Parents were given the option of being present during blood sampling (36.4%), intravenous line placement (32.7%), urethral catheterization (32.1%), lumbar puncture (13.5%), and resuscitation (1%). More than 60% of providers approved of FP during blood sampling, sutures, intravenous line placement, and urethral catheterization; however, only 10.8% of providers encourages FP during resuscitation. Against FP, health care staff argue procedural invasiveness (75.6%), parents' anxiety (87.6%), and worsened performance of the procedure (66%). Commonly expressed advantages were reducing patient distress (72.9%) and parent anxiety (62.3%). Physicians, especially the older ones, are more likely to encourage FP than nurses for some IPs.

CONCLUSIONS

The PED staff tend to prefer parents not to be present during IPs as the level of invasiveness increases. Family presence is not common in Spanish PEDs. Older physicians are more likely to support FP than nurses.

Neurotransmitters excreted in the urine as biomarkers of nervous system activity: validity and clinical applicability

Strategies for managing the nervous system are numerous while methods of evaluating the nervous system are limited. Given the physiological importance of neurotransmitters as signaling molecules in the nervous system, the measurement of neurotransmitters has significant potential as a clinical tool. Of all the biological fluids that can be utilized, urinary neurotransmitter testing, due to its stability, sensitivity, and non-invasiveness, is the desired method to analyze nervous system function. Increasing use of this technology in a clinical setting demands a review of its feasibility, utility, and clinical value. We review the current body of literature pertaining to the mechanism of neurotransmitter transport across the blood-brain barrier as well as neurotransmitter filtration and excretion by the kidneys. In addition, this review summarizes the historical use of urinary neurotransmitter assessment to diagnose pheochromocytoma. Early research also correlated urinary assessment of neurotransmitters to various clinical symptoms and treatments of which we present research only for depression, ADHD, and inflammation because of the abundant amount of research in these areas. Finally, we review the limitations and challenges of urinary neurotransmitter testing. Taken together, evidence suggests that neurotransmitters excreted in the urine may have a place in clinical practice as a biomarker of nervous system function to effectively assess disturbances and monitor treatment efficacy.

Pediatric residents' ability to perform a lumbar puncture: evaluation of an educational intervention

OBJECTIVE

To assess the baseline ability of pediatric residents to successfully perform a lumbar puncture (LP) and to evaluate the impact of an educational intervention on this skill in both a simulated and clinical environment.

METHODS

An experimental group of first-year residents and a control group of second-year residents were enrolled in a prospective nonrandomized intervention study. Knowledge and skill at performing LPs were assessed using a written and a simulated LP test. The experimental group was tested at the start of their residency and then received the educational intervention. They were retested 6 months later. The control group did not receive the educational intervention and were tested at the start of their second year. The outcomes of clinical LPs performed by the 2 groups were also recorded.

RESULTS

The experimental group showed significant improvement on both the written and the simulated LP test after the educational intervention. When compared with the control group, they performed the simulated LP significantly better as measured by the number of correctly performed steps. Both groups performed a low number of clinical LPs.

CONCLUSIONS

After an educational intervention, pediatric first-year residents performed a simulated LP better than a group of second-year residents who had greater clinical LP experience. The low number of clinical LPs performed limits our ability to determine the educational intervention's impact in the clinical setting and reinforces the concern that recent changes to pediatric residencies may negatively impact residents' procedural experience.

"Traumatic tap" proportion in pediatric lumbar puncture

OBJECTIVES

To determine the frequency of "traumatic" or "bloody" tap when pediatric lumbar puncture is performed by a physician who has completed training and performs the procedure frequently.

METHODS

The author identified 100 sequential patients presenting to a pediatric emergency department requiring lumbar puncture for clinical indications. Demographic information, cerebrospinal cell counts, and other relevant data were later obtained by retrospective chart review. Cell count results were categorized according to several previously used criteria: greater than 400, greater than 1000, and greater than 10,000/unsuccessful.

RESULTS

One procedure yielded only a small amount of bloody fluid on which no cell count was performed. The remaining 99 procedures yielded red blood cell counts less than 1000.

CONCLUSIONS

The proportion of bloody or traumatic results from pediatric lumbar puncture reported from pediatric training centers is typically in the 20% to 30% range. This represents an overestimation of a more ideal proportion possible when the procedure is performed by a physician who has completed training and performs the procedure frequently.

[Are parents present during invasive procedures? Assessment in 32 Spanish hospitals]

INTRODUCTION

Parental participation in medical decisions involving their children is essential and family presence during invasive procedures (IP) is fundamental.

OBJECTIVES

1) To determine the frequency of parental presence during different IP in Spanish Paediatrics Emergency Departments (PED). 2) To assess the reasons for restricting parental presence. 3) To evaluate the agreement of health care professionals with regards to parental presence.

MATERIALS AND METHODS

Descriptive multicentre study based on questionnaires sent to physicians in charge of different Spanish PED.

RESULTS

Thirty-two out of 43 questionnaires were replied. Family presence during IP is never allowed in 11 hospitals. In the rest, this varies depending on the type of IP: blood sampling (15 hospitals), wound suture (14), urethral catheterization (9), lumbar puncture (7), intubation (1) and cardiopulmonary resuscitation (1), with no significant differences between hospitals. The main arguments for restricting parental presence are parental anxiety (26/30) and a lower performance by health personnel (23/30). Occasional problems, such as nausea (22/28), have arisen due to family presence. The interviewed physicians in charge think that health care professionals' agreement rates for parental presence decrease significantly with the increasing invasiveness of the procedure. Two hospitals have a working group and one a specific protocol to address parental presence.

CONCLUSIONS

Parental presence during IP is limited in Spanish PED, due to parental anxiety and is detrimental to the success of the procedure. Physicians and nurses disagree with family presence, especially during the most invasive procedures.

A positioning pillow to improve lumbar puncture success rate in paediatric haematology-oncology patients: a randomized controlled trial

Background

Lumbar punctures (LPs) are common in children with cancer. Although pain management during the lumbar puncture has been well standardized, dealing with stress and anxiety is not well addressed yet. Our objective was to evaluate the potential improvement of the LP success rate using a positioning pillow, to ensure maximum lumbar flexion, and allow paravertebral muscles to relax, in children who are awake, with either conscious sedation or no sedation.

Methods

Children aged 2–18 years undergoing LP were randomly assigned to a positioning pillow or no intervention. The primary outcome was the rate of success, i.e. achieving the LP (sampling or injection) at the first attempt, without bleeding (RBC < 50/mm³). The secondary outcomes included: the child's pain, assessed by a self-administered visual analogical scales (VAS) for children over 6 years of age; the parents' and caregivers' perception of the child's pain; the satisfaction of the children, the parents, the caregivers and the physician. The child's cooperation and the occurrence of post-LP syndrome were also evaluated.

Results

124 children (62 in each group) were included. The LP pillow tended to increase the success rate of LPs (67% vs. 57%, p = 0.23), and decreased the post-LP syndromes (15% vs. 24%, p = 0.17) but the differences were not statistically significant. In children over 6-year of age (n = 72), the rate of success was significantly higher in the pillow group (58.5% vs. 41.5%, p = 0.031), with a tendency to feel less pain (median VAS 25 vs. 15 mm, p = 0.39) and being more satisfied (84.4% vs. 75.0%, p = 0.34).

Conclusion

Overall results do not demonstrate a benefit in using this pillow for lumbar punctures. This study results also suggest a benefit in the sub group of children over 6-year of age; this result needs confirmation.

Trial Registration

The trial was registered with Clinical Trials.gov (number NCT00775112).