SPINAL TAPS!// 5 + steps to PREPARE a baby!

You know how they say that spinal taps are all in the holding. Well, today we're going to go over how to hold a baby for the spinal tap so you can be the best possible holder in the NICU. Hi, I'm Dr. Tala, and I've been a neonatologist for 16 years now. And as you all know, we do a lot of lumbar punctures in the unit. And as you also know, a really good holder makes spinal taps so much easier. Today, we're going to go over five things you need to consider when you're holding a baby for a tap. One, let's start with talking about the actual position the baby is in. A recent paper came out that showed that you're more likely to be successful with an LP if the baby is in a sitting up position. I will say that about 90% of those babies in the study were term or post-term, and they only randomized down to 27 weeks. And less than 2% of all the babies were on any sort of positive airway pressure. So basically, mostly bigger, healthier babies were in the study. I'm used to using the sitting position with older kids, but honestly, I can't remember the last time I've seen anyone do this in the NICU. But if the baby is in a sitting position, you're basically bending the baby over with the face pointing kind of towards the baby's knees. We'll talk about this more later. More commonly, we do the side-lying position, and that's what I'm going to focus on here, because I have much more experience with this in the unit. Generally, the overall height of the baby should be similar to when we're intubating. So we kind of want the table level, the level of the lower ribs of whoever's doing the spinal tap. Because I'm right-handed, it's easier for me to have my left hand closest to the baby's head. So I can use the left hand for determining the position where I'm going to go in. So I always like the baby being in a left-side-down situation, as if you're shooting a left lateral decubitus x-ray with the liver up. So this is kind of the rough position you want the baby in. We'll talk more about the actual flexing and the holding of the baby in a little bit. Two, pain control. And this is a really important one. Many LPs are done without any attempts at pain control at all, and that really shouldn't be happening. So make sure that you're being an advocate for your patient. I really can't think of any situation where you're so desperate to get the tap that you don't have time to control pain in some way for the baby. Ideally, what we want is the baby to feel soothed and relaxed and comfortable in the position that it's in. We definitely don't want the baby kicking and fighting, because that's horrible for the baby, but also it clenches up all the back muscles, and it makes it almost impossible to get the needle into the correct space. Gentle moving and holding the baby is going to be key. Anything that we can do to non-pharmacologically help the situation would be great. So you want a quiet, not too bright room. So maybe dim the lights just a little bit. Sometimes I put on classical music. I love Schubert, which actually is romantic music, but that's a different video. But I feel like that can really soothe babies as well. We don't want the baby to have just eaten, because then we're worried about reflux and vomiting. Obviously, we also don't want the baby starving. So maybe an hour, an hour and a half after the last feed is kind of ideal. And then if the baby is capable of taking something by mouth, then maybe give them a few sucrose drops or some sweet ease. And that's been shown if you give that, a few minutes before the procedure, that that can actually blunt the pain response as well. Use warm blankets when you're actually holding the baby. That can help. With older babies for pain control, we can use Emla, which is like the local anesthetic, which comes in an ointment. So you directly put the cream really on the baby's back, exactly where you're going to tap the baby. That needs to be done about 30 to 60 minutes before the procedure is done. Some places also directly inject lidocaine into the area. Honestly, we don't really do that very often, mostly because you can argue that if you're going to be injecting with something, then it might as well just be the needle for the tap. The lidocaine itself is thought to really sting as well. We're less likely to use Emla or lidocaine in younger babies because their skin is so thin and we're really worried about systemic absorption. So those are really things that you would only do in term babies. If the baby is intubated, then we're a little less terrified about giving pain medications for the procedure because obviously we're not as worried about suppressing that respiratory drive. So often we'll use narcotics. For example, we'll use fentanyl at one to two mics per kilo or a dose of morphine at 0.05 mgs to 0.1 mgs per kg. Often the babies just don't like being held in that position. So it isn't so much the pain response, but they're just uncomfortable. So for that, we may give them a benzodiazepine, something like Versed or Midazolam at about 0.1 mgs per kg. Again, this is not a pain medication. We're just doing it to relax the baby and to hopefully help with the spinal tap. If we don't have an IV, then we can give oral morphine, similar dosage, or we can give intranasal Midazolam or intranasal Versed at about 0.2 mgs per kg. These can work really well as well. As you all know, none of these medications are good for babies. And we're especially worried about them if they're not intubated because they might actually suppress their breathing. So always start small and then just give another small dose if that doesn't seem to be affecting the baby enough. I would say that one of the most common reasons we don't actually get the spinal tap is because the baby is too wild and it's just really difficult to insert that needle in to the right place. So if the baby really is too active, then have a conversation with the team and stop the procedure and decide what you need to do or give the baby next so that we can all make this happen. Three, safety. Obviously, this is the most critical aspect of doing a spinal tap. Sometimes we can't do a spinal tap when we really do need to do it because the baby is too sick and just won't tolerate it. So sometimes we have to wait until the baby is off 100% oxygen or on a lot of presses or whatever else until the baby is stable enough to be able to do the tap. In babies at risk for IVH, so especially the really small babies, you should probably be waiting about 72 hours until you actually perform that initial tap just so that you're over the peak stages of the baby getting IVH. But even if the baby is super stable, obviously the baby needs to be monitored carefully during the tap. Sometimes just putting them in this position is enough to cause bravies and D-sats on the baby. What babies really hate the most is when there's a lot of flexion at the level of the neck. This causes really bad bravies and D-sats. So what's more important is that the actual back is bent, not so much the neck. And bending and hyper-flexing the neck really doesn't help open up the back at all. So it's more kind of this position rather than bending at the neck. And again, there is some data that babies have fewer events when they're in the sitting up position for the spinal tap, probably because we're less inclined to actually flex that neck. So again, in these term babies at least, that's probably something we should be moving towards. In the NICU, the baby will be on a monitor during the procedure. So we'll be watching the heart rate and sats. If it's a healthy term newborn, maybe you're checking a VDRL in the term nursery, then you don't necessarily have to be putting the baby on a monitor, but just make sure that you're following really good visual clues. If the baby is intubated, then make sure that the ET tube is very secure in whatever position that the baby is in. Obviously with that much movement, it's very easy for the ET tube to come out or get dislodged. Sometimes for the sickest babies, we actually have a respiratory therapist right there to help too. Even if the baby is on non-invasive support, so NIPPV or CPAP or nasal cannula, with a lot of wiggling and moving, sometimes the prongs can come out of the nose or the mask can get dislodged. So always keep a good eye on that and make sure that the babies are getting the respiratory support that they need. Sometimes in the sickest ones, we actually have to go up on the FIO2 just to keep their SATs okay during the procedure. Don't do this automatically, only do it if the baby's SATs are going down just a little bit. Remember, the baby's safety is more important than getting the LP. So if the baby is bradying or desatting or whatever, then reposition the baby, straighten up the neck or whatever it is to make sure that that heart rate comes back up again. Sometimes the baby just doesn't tolerate the procedure at all and we just have to stop the procedure and make a plan of what to do in the future. Four, monitoring for sterility. One of the risk factors of actually doing a spinal tap is actually introducing a pathogen into the cerebrospinal fluid as you're doing the spinal tap. Obviously, this should be a never event and the way we make that a never event is by making sure that all the area is very clean and disinfected. Sometimes if the baby is kicking and thrashing around, which hopefully they're not, it can be quite hard keeping the sterile field. So be aware of that too. Every hospital has different protocols on what they should be wearing for a spinal tap. So whether it's a cap, gown, mask, or some combination of those three, and then obviously anybody actually near the field should be wearing sterile gloves as well. Be aware of all of this as you're holding. If you feel like the sterility of the field has been broken, then say something for the good of everybody. As an aside, we obviously don't want stool anywhere near the sterile field. So if the baby pooped before you're doing the tap, then that has to be cleaned. If the baby poops during the lumbar puncture, then evaluate how close that is to the sterile field. If you feel like it's impinging in any way, then the procedure has to be stopped and the baby needs to be cleaned. Five, physically holding the baby. This is super tough because in the sideline position, you need to make sure that all the limbs are not moving around and the back is flexed and the baby can still breathe. It's not easy and sometimes it takes two people. Whether the baby is sitting up or on its side, ideally we want the back flexed as much as possible to open up the space between the spinous processes. Again, that does not mean that the chin needs to be flexed, but the hips and the knees should be flexed. So you can use one hand to hold the legs and then one hand to hold the legs and the arms, ideally. In the sideline position, we often miss the subarachnoid space where the CSF is because we've gone too high or too low or basically too lateral. So another crucial aspect of holding is making sure that the side is nice and flat and that the spine is effectively a parallel line to the table. If the baby is twisted too much one way or another, then we'll miss it. So you don't want the baby rolled too much either way. And if you are rolling the baby, the back needs to be moved as one, not just the legs higher. In the next video, I'll show you how I like to place my sterile towels, so I can make extra sure that I have good landmarks and I'm able to get exactly the middle of the back. In the sitting up position, again, the hips and knees are flexed and you use one hand on each side to hold the baby in that position. Again, make very sure that the breathing apparatus is safe here, whatever that is. Like we said, hopefully you're mostly going to be doing this position in older, healthier babies. Okay, that's it. Now you can be the perfect holders. If you reach this far, then please like this video and subscribe to this channel if you're interested in other aspects of neonatal education. Your homework assignment is to name three ways in which you can help make the spinal tap as successful as possible. Right, now go watch the next video on spinal taps.