163
Pubmed via medline was searched, details are as follows: Reseach strategy: ((“Spinal Puncture”[Mesh]) OR spinal puncture*) OR lumbar puncture*) OR spinal tap*) OR lumbar tap*) OR LP)) AND ((ultrasonography) OR medical sonography) OR ultrasonic imaging) OR echography) OR ultrasonic diagnos*) OR ultrasound diagnos*) OR ultrasound-assisted) OR echo-guided) OR POCUS) OR Point of care ultrasound) OR “Ultrasonography [Mesh])) OR U/S)=506 results Embase was searched, details are as follows:
SEARCH STRATEGY
In (obese and non-obese adults patients who need a lumbar puncture), should (ultrasound) be (used to localise the right space and improve first attempt success and reduce rate of traumatic tap)?
THREE-PART QUESTION
While working the night shift, a patient is admitted for thunderclap headache 12 h ago. After a negative head CT, you decide to do a lumbar puncture to rule out subarachnoid haemorrhage. You specifically need a non-traumatic lumbar puncture (LP) and you wonder if localising the right lumbar space with an ultrasound would reduce the rate of traumatic LP.
CLINICAL SCENARIO
ABSTRACT A short cut review was carried out to establish ultrasound can assist. 9 papers were found of which 4 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that using ultrasound assisted landmarks prior to LP improves success rate and reduces the number of attempts and traumatic taps.
Authors: Audrey-Anne Brousseau, Dr Marc-Charles Parent Institution: Université Laval, Québec, Canada
BET 3: ADVANTAGES OF ULTRASOUND-ASSISTED LUMBAR PUNCTURE
Best evidence topic reports
Downloaded from http://emj.bmj.com/ on February 20, 2016 - Published by group.bmj.com
Emerg Med J February 2016 Vol 33 No 2
Relevant papers
Author, date and country
Mofidi et al, 2013,2 Iran
Shaikh et al, 2013,3 Canada
Study type
Outcomes
Key results
Study weaknesses
Adults >18 years old, who needed an LP; In an ED setting. All patients had a prior ultrasound to localise the right space and marked with an ultraviolet (UV) ink in a separate room, the LP operator then localised the right space by placing an UV ink by palpation landmarks. Randomisation occurred after that. A different investigator showed the mark to be used based on the randomisation results to the LP operator who was blinded to the origin of the mark
Randomised controlled double-blind study
Number of attempts Presence of a traumatic tap Success or failure of procedure
No significant difference in number of attempts (2 vs 2) No significant difference (RR=1.04 (95% CI 0.83 to 1.31)) Increased success rate for USS (RR 1.32 (95% CI 1.01 to 1.72)), 1 failed in the USS and 6 in the PL procedure No significant difference (15 min in the USS group vs 10.5 min in the PL group) No significant difference (3 in the USS group vs 5.2 in the PL group)
Subgroup analysis very interesting but probably lacks power due to a small sample size. For the USS procedure, the localisation of the right angle was not included in the procedure
Adults >18 years old 30 Number of attempts Number of traumatic LP Pain score with a numerical 0 to 10 scale Procedure time Failed procedure
Traumatic procedure Number of needle reinsertion Number of needle redirection Time of the procedure
Peterson et al, 2014,4 USA
Emerg Med J February 2016 Vol 33 No 2
Adult ongoing LP for any clinical indication. In an ED setting. Randomisation to the USS group or the PL group. The USS group: the right space was priory localised with the standard USS procedure then the usual LP procedure
Prospective randomised controlled trial
Number of needle reinsertion Success of LP (return of a non-traumatic CSF) Pain measured on a VAS Patient satisfaction (5-point Likert scale) Median time of procedure
Ease of procedure significantly better (2.7 cm for USS vs 6.9 cm for PL), Others results had no significant difference but there was a trend towards the USS procedure Reduced number of attempts (1 in the USS group vs 2 in the PL group, p=−0.047) Reduced number of traumatic taps (5 in the USS group vs 18 in the PL group, p=0.024) In the USS guided LP, the pain score was significantly lower (4.4 vs 7.4) Time (min) was significantly lower in the USS group 3.3 vs 6.4 min Reduced failed procedure, 6 in the USS group vs 44 in the PL group (RR 0.21 (95% CI 0.10 to 0.43)), NNT 16 to reduce one failure Reduced traumatic procedure (RR 0.27 (95% CI 0.11 to 0.67)) Reduced number of reinsertion of needle by a mean of −0.44 (−0.64 to −0.24) Reduced number of redirection by a mean of −1.00 per procedure (−1.24 to −0.75, p
Pubmed via medline was searched, details are as follows: Reseach strategy: ((“Spinal Puncture”[Mesh]) OR spinal puncture*) OR lumbar puncture*) OR spinal tap*) OR lumbar tap*) OR LP)) AND ((ultrasonography) OR medical sonography) OR ultrasonic imaging) OR echography) OR ultrasonic diagnos*) OR ultrasound diagnos*) OR ultrasound-assisted) OR echo-guided) OR POCUS) OR Point of care ultrasound) OR “Ultrasonography [Mesh])) OR U/S)=506 results Embase was searched, details are as follows:
SEARCH STRATEGY
In (obese and non-obese adults patients who need a lumbar puncture), should (ultrasound) be (used to localise the right space and improve first attempt success and reduce rate of traumatic tap)?
THREE-PART QUESTION
While working the night shift, a patient is admitted for thunderclap headache 12 h ago. After a negative head CT, you decide to do a lumbar puncture to rule out subarachnoid haemorrhage. You specifically need a non-traumatic lumbar puncture (LP) and you wonder if localising the right lumbar space with an ultrasound would reduce the rate of traumatic LP.
CLINICAL SCENARIO
ABSTRACT A short cut review was carried out to establish ultrasound can assist. 9 papers were found of which 4 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that using ultrasound assisted landmarks prior to LP improves success rate and reduces the number of attempts and traumatic taps.
Authors: Audrey-Anne Brousseau, Dr Marc-Charles Parent Institution: Université Laval, Québec, Canada
BET 3: ADVANTAGES OF ULTRASOUND-ASSISTED LUMBAR PUNCTURE
Best evidence topic reports
Downloaded from http://emj.bmj.com/ on February 20, 2016 - Published by group.bmj.com
Emerg Med J February 2016 Vol 33 No 2
Relevant papers
Author, date and country
Mofidi et al, 2013,2 Iran
Shaikh et al, 2013,3 Canada
Study type
Outcomes
Key results
Study weaknesses
Adults >18 years old, who needed an LP; In an ED setting. All patients had a prior ultrasound to localise the right space and marked with an ultraviolet (UV) ink in a separate room, the LP operator then localised the right space by placing an UV ink by palpation landmarks. Randomisation occurred after that. A different investigator showed the mark to be used based on the randomisation results to the LP operator who was blinded to the origin of the mark
Randomised controlled double-blind study
Number of attempts Presence of a traumatic tap Success or failure of procedure
No significant difference in number of attempts (2 vs 2) No significant difference (RR=1.04 (95% CI 0.83 to 1.31)) Increased success rate for USS (RR 1.32 (95% CI 1.01 to 1.72)), 1 failed in the USS and 6 in the PL procedure No significant difference (15 min in the USS group vs 10.5 min in the PL group) No significant difference (3 in the USS group vs 5.2 in the PL group)
Subgroup analysis very interesting but probably lacks power due to a small sample size. For the USS procedure, the localisation of the right angle was not included in the procedure
Adults >18 years old 30 Number of attempts Number of traumatic LP Pain score with a numerical 0 to 10 scale Procedure time Failed procedure
Traumatic procedure Number of needle reinsertion Number of needle redirection Time of the procedure
Peterson et al, 2014,4 USA
Emerg Med J February 2016 Vol 33 No 2
Adult ongoing LP for any clinical indication. In an ED setting. Randomisation to the USS group or the PL group. The USS group: the right space was priory localised with the standard USS procedure then the usual LP procedure
Prospective randomised controlled trial
Number of needle reinsertion Success of LP (return of a non-traumatic CSF) Pain measured on a VAS Patient satisfaction (5-point Likert scale) Median time of procedure
Ease of procedure significantly better (2.7 cm for USS vs 6.9 cm for PL), Others results had no significant difference but there was a trend towards the USS procedure Reduced number of attempts (1 in the USS group vs 2 in the PL group, p=−0.047) Reduced number of traumatic taps (5 in the USS group vs 18 in the PL group, p=0.024) In the USS guided LP, the pain score was significantly lower (4.4 vs 7.4) Time (min) was significantly lower in the USS group 3.3 vs 6.4 min Reduced failed procedure, 6 in the USS group vs 44 in the PL group (RR 0.21 (95% CI 0.10 to 0.43)), NNT 16 to reduce one failure Reduced traumatic procedure (RR 0.27 (95% CI 0.11 to 0.67)) Reduced number of reinsertion of needle by a mean of −0.44 (−0.64 to −0.24) Reduced number of redirection by a mean of −1.00 per procedure (−1.24 to −0.75, p
