Procedure Notes: Lumbar Puncture

Lumbar Puncture

Date: <____>
Time: <____>
Indication: Altered Mental Status
Resident: <____>
Attending: <____>

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in the <LEFT/RIGHT> lateral decubitus position in a semi-fetal position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion. 1% lidocaine was used anesthetize the surrounding skin area. A <20-gauge 3.5-inch> spinal needle was placed in the <L3-L4/L4-L5> interspace. Clear cerebral spinal fluid was obtained and the opening pressure was noted to be <?cm>. Four tubes were filled with 4 mL of CSF. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. <Attending/Resident> was present for the entire procedure

Estimated Blood Loss: <____>
The patient tolerated the procedure well and there were no complications.

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1 comment

  1. Michael

    Please use a 25ga. nontraumatic tip spinal needle for this procedure (via a 18ga introducer needle). 20 and 22ga Quinke tip (cutting tip) are associated with avoidably high post dural puncture rate. And….you don't want to treat that if it can be avoided. The manometer reading amongst ALL n eedles will be the same, albiet the narrower gauge will take a minute longer to equilibrate. A worthwhile exchange. Ask your anesthesia department for the non cutting tip 25 gauge spinal needles.

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