Is there anywhere that defines the WBC's allowed in CSF that can be considered normal (i.e.: not concern for meningitis)? Because if I do the subtraction for RBC's, will it have to come down to zero? I have used 2 or less for adults because that is how I was trained but not sure if that is evidence based or applies to children.
In terms of correction, I was never much of a fan, but there was a big PECARN study published in May 2017 (Lyons et al.) which basically found that 1W to 877R was the ideal correction factor. Thankfully, they found that 1:1000 worked about as well and was much easier. However, there were some missed in the 0-28 day group, so they suggested applying this mainly to the 29-60 day olds. They used 10 as their WBC cutoff in 29-60 day olds. However, the Philadelphia criteria use <8 as the cut-off for CSF WBCs for low risk and that is what I have always used. Under 1 month, 15-30 is thought normal, and for the purposes of this study, they used 20.
I still don't quite have the hang of ultrasound for LP, but it is on my New Years resolution list! If you use it effectively in adults, you can probably extrapolate to kids. There is some pediatric literature indicating increased first-attempt success rates with US, but an addition of 5 minutes to the procedure (May Annals EM). Like everything, a trade-off, but for those who find neonatal LPs to be the bane of their existence, US can potentially make them ~25% less so! Even with US, though, there is a decent failure rate- I presume from all the squirming AFTER landmark location.
I do occasionally in adults when I think I'm really close. I happen to work at a center where many adults have a lot of subcutaneous tissue. I'm concerned about clogging up the needle if I take the stylet out too soon. I 've also seen a few needles bend when "walking up the bone" in some of our more difficult to palpate patients. I feel like there are just more potential pitfalls to navigate. Sorry if I overstated
To join the conversation, you need to subscribe.
Sign up today for full access to all episodes and to join the conversation.
Super Sick DKAFull episode audio for MD edition264:53 min - 369 MB - M4AEM:RAP 2017 November Canadian EditionCanadian29:05 min - 40 MB - MP3EM:RAP 2017 November German EditionDeutsche59:58 min - 82 MB - MP3EM:RAP 2017 November Spanish EditionEspañol98:20 min - 135 MB - MP3EM:RAP 2017 November Aussie EditionAustralian1:06 min - 2 MB - MP3EM:RAP 2017 November French EditionFrançais25:13 min - 35 MB - MP3EM:RAP 2017 November Board Review Answers99 KB - PDFEM:RAP 2017 November Board Review Questions309 KB - PDFEM:RAP 2017 November Individual MP3s335 MB - ZIPEM:RAP 2017 November Individual Written Summaries3 MB - ZIPEM:RAP 2017 November Spanish Show Notes1 MB - PDFEM:RAP 2017 November Written Summary2 MB - PDF
David G. - November 8, 2017 8:22 PM
Is there anywhere that defines the WBC's allowed in CSF that can be considered normal (i.e.: not concern for meningitis)? Because if I do the subtraction for RBC's, will it have to come down to zero? I have used 2 or less for adults because that is how I was trained but not sure if that is evidence based or applies to children.
ilene c. - November 9, 2017 12:28 AM
In terms of correction, I was never much of a fan, but there was a big PECARN study published in May 2017 (Lyons et al.) which basically found that 1W to 877R was the ideal correction factor. Thankfully, they found that 1:1000 worked about as well and was much easier. However, there were some missed in the 0-28 day group, so they suggested applying this mainly to the 29-60 day olds. They used 10 as their WBC cutoff in 29-60 day olds. However, the Philadelphia criteria use <8 as the cut-off for CSF WBCs for low risk and that is what I have always used. Under 1 month, 15-30 is thought normal, and for the purposes of this study, they used 20.
Dallas H. - November 20, 2017 7:45 AM
I am not sure about the literature for neonatal but ultrasound guided LPs are awesome for adults with challenging anatomy.
ilene c. - November 21, 2017 1:19 PM
I still don't quite have the hang of ultrasound for LP, but it is on my New Years resolution list! If you use it effectively in adults, you can probably extrapolate to kids. There is some pediatric literature indicating increased first-attempt success rates with US, but an addition of 5 minutes to the procedure (May Annals EM). Like everything, a trade-off, but for those who find neonatal LPs to be the bane of their existence, US can potentially make them ~25% less so! Even with US, though, there is a decent failure rate- I presume from all the squirming AFTER landmark location.
Mike P. - November 22, 2017 1:37 PM
I’ve been removing the stylet early in adults for years - what are the reasons you do it in kids but not adults?
ilene c. - November 22, 2017 10:08 PM
I do occasionally in adults when I think I'm really close. I happen to work at a center where many adults have a lot of subcutaneous tissue. I'm concerned about clogging up the needle if I take the stylet out too soon. I 've also seen a few needles bend when "walking up the bone" in some of our more difficult to palpate patients. I feel like there are just more potential pitfalls to navigate. Sorry if I overstated