close
Indications :
1. CNS infection : meningitis, encephalitis
2. SAH
3. Demyelinating disease
4. For tumor marker, leukemia
腫瘤標記(tumor marker)或腫瘤細胞測定
5. 脊髓麻醉
6. 特殊治療之脊髓內注射 : intrathecal chemotherapy
7. Myelogram 脊髓顯影
Contraindication :
1. Local infection
2. Coagulopathy --> Spinal hematoma
3. IICP : Headache, vomiting, papilloedema
4. Focal NE sign r/o brain occupying lesion
5. Obstructive hydrocephalus
INR 1.5 (TPA 是 1.7) ; 血小板 2 萬
血小板五萬還行
Antiplatelet drugs, such as aspirin and clopidogrel, offer such a low added risk to an emergent procedure
that it is recommended to proceed without delay.
Complications
Post puncture headache
lumbar puncture 前先 hydration
之後平躺 6-12 hr keep hydration
給止痛藥
Most common complication
Over frontal or occipital
continuous CSF leakage from the dural puncture site
Traction on bridging vessels, dura, and nerves causes headache.
Usually begins 24 - 48 hours after the procedure
intensified when the patient is sitting or standing upright and with Valsalva maneuvers such as coughing.
The headache improves or resolves when the patient is supine.
Post–lumbar puncture headache does not seem to be related to the opening pressure,
the volume of CSF removed, or bed rest after the procedure. Postprocedural bed rest does not prevent this complication.
教科書 : 平躺沒有幫助 ~ 和初壓無關 ~ 和引流多少也無關
Persistent headache (>24 hours) can be treated with an epidural blood patch.
使用筆型尖端的針具 (Atraumatic needle, Whitacre) 相較常規使用的斜面針具 (bevel type needle) needle)，可減少腰椎穿刺後頭痛的併發症
另外 Size 小的也可以 (smaller needle size)
Infection
Spinal hematoma
Severe or persistent back pain after the procedure, radicular pain,
new neurologic symptoms, or sphincter disturbance
indicates that a spinal hematoma may be present.
Most present within the first 6 hours.
MRI -> NS
- Aspirin/Clopidogrel :
low added risk to an emergent procedure
that it is recommended to proceed without delay
- Wafarin : INR < 1.5
- Heparn : 24 小時
- NOAC 未知
CSF 在 Subarachnoid space
要穿過 flavum, dura, arachnoid
Echo guide 意義在於 定位 上下的 spinous process
估測 interspinous space 寬度, 也評估病人 position 擺的好不好
最後則是預估到 dura 深度
或許很難看清楚 flavum, dura 這些層
但至少可以看到最下面是 vertebrae
https://www.youtube.com/watch?v=weoY_9tOcJQ
22-gauge needle
Use of a needle larger than 20 gauge may double the incidence of post–lumbar puncture headache
步驟：
- 患者左側臥於硬板床，弓起背腰部份，雙膝儘量彎曲靠近腹部，蝦米姿勢
頭, 腰可墊枕頭, 兩腿間夾著枕頭，保持背部脊椎水平脊椎水平是擺位重點 :
定位 transverse line drawn between the iliac crests crosses the spine at the L4 spinous process
L3/4，L4/5，L5/S1
L4-L5 interspace is the most com monly used interspace for lumbar puncture
- 消毒, 最大無菌面
- Puncture 技術個人喜歡垂直入針, 針往頭側傾斜 15 度
- 移出穿刺針之內針，接上 3 way，測 Opening Pressure
收集標本分裝各個試管 (六管)
作生化(蛋白質、醣類)、血清免疫、梅毒、細胞學、細菌學等檢查用 - Closing Pressure測量
- 移出腰椎穿刺針，並蓋上無菌紗布塊，用膠布固定之
ICP normal < 15 mmHg (20 cm H2O)
IICP : > 20 mmHg = 25 cm H2O
坐著 or 極端極度彎曲姿勢 = CSF 測量的壓力會上升
Pressures measured with the patient still curled in extreme flexion or sitting may be artificially elevated
備註：
姿勢沒擺好，是腰椎穿刺失敗的主因
不可用彈簧床或軟墊床，否則會造成脊柱彎曲或傾斜，以至於穿刺針偏離棘突間隙
流出含血的腦脊髓液時：
必須區分是因進針時傷及血管(traumatic tap)
還是腦脊髓液原本就含有血(SAH)
此時採連續三支試管收集腦脊髓液並檢視之
外傷者之血應分布不均勻，其三支試管之含血量應漸少，顏色越來越淡
蛛網膜下腔出血分布均勻，三支試管之血色濃度一致
流不出腦脊髓液時：可能是針口被一些組織或神經根堵住
此時只需旋轉針頭或稍調整深度即可
也可見於蛋白質濃度太高，以致腦脊髓液過於黏稠流不出來
或是壓力太低造成，此時可用空針吸取，但不可過於用力 (還是建議不要抽 ...)
要確定是否有腦脊髓液，祇要用肉眼觀察針孔即可
切勿將穿針的內針任意在手套上劃，以測試是否有液體的痕跡
這樣容易將手套上的化學物質(滑石粉)帶入蛛網膜下腔，造成化學性腦膜炎
文章標籤
全站熱搜
留言列表
CV (7)
