Fellow: Fatuma Barqadle, MD, Children's Hospital Los Angeles/University of Southern California, Keck School of Medicine
Article: Neal JT, Kaplan SL, Woodford AL, Desai K, Zorc JJ, Chen AE. The effect of bedside Ultrasonographic Skin Marking on Infant Lumbar Puncture Success: A Randomized Controlled Trial. Annals of Emergency Medicine 2017; 69:610–619.
Summary: Neal et al, performed a prospective, randomized, controlled clinical trial comparing ultrasonography-assisted site marking with traditional lumbar puncture in infants aged 6 months or younger who presented to a single academic pediatric emergency department. The primary outcome was a successful first attempt lumbar puncture in infants, defined as CSF with RBC <1000/mm3 and the secondary outcomes included lumbar puncture success within 3 attempts as well as a re-evaluation of lumbar puncture success to include CSF that had RBC <10,000/mm3. Study results showed a 27% improvement in infant lumbar puncture success rate on first attempt and a 31% improvement within 3 attempts when the procedure was performed with ultrasound assisted skin marking compared to the traditional method.
What are the key strengths of the article?
This was a randomized controlled trial with sound methodology. It focused solely on infants, a population that continues to be at high risk for failed lumbar punctures, in comparison to the other ultrasound assisted lumbar puncture studies to date.
Are there any limitations or flaws in the article?
This study was conducted at a single pediatric ED with a small number of sonographers who had varied ultrasound training. As such, it may not be generalizable to other settings, especially resource poor settings. Furthermore, although the study reported that success did not vary with experience level, nearly all lumbar punctures in both arms were performed by trainees (>97%) and the majority had little to zero experience.
What is the major takeaway message?
Ultrasound guided site marking improved infant lumbar puncture success rates with a number needed to treat of four. However, further studies are necessary to elucidate the generalizability of these findings and the impact on patient care (i.e. need for other procedures, exposure to antibiotics) and overall hospital resource utilization and cost.
Describe how this article should impact our practice:
Building on the advances in point of care ultrasonography and it’s increasing popularity and utilization in pediatrics, this article makes a strong case for ultrasound assisted lumbar punctures as an avenue for increasing procedure success rates, particularly in trainees. However, in the hands of more experienced providers and hospitals with less resources, the effects of this study are less clear. Further investigation into the generalizability of these results and a better outline of the necessary training and costs is warranted before a widespread commitment to changing standard practice.
Article: Neal JT, Kaplan SL, Woodford AL, Desai K, Zorc JJ, Chen AE. The effect of bedside Ultrasonographic Skin Marking on Infant Lumbar Puncture Success: A Randomized Controlled Trial. Annals of Emergency Medicine 2017; 69:610–619.
Summary: Neal et al, performed a prospective, randomized, controlled clinical trial comparing ultrasonography-assisted site marking with traditional lumbar puncture in infants aged 6 months or younger who presented to a single academic pediatric emergency department. The primary outcome was a successful first attempt lumbar puncture in infants, defined as CSF with RBC <1000/mm3 and the secondary outcomes included lumbar puncture success within 3 attempts as well as a re-evaluation of lumbar puncture success to include CSF that had RBC <10,000/mm3. Study results showed a 27% improvement in infant lumbar puncture success rate on first attempt and a 31% improvement within 3 attempts when the procedure was performed with ultrasound assisted skin marking compared to the traditional method.
What are the key strengths of the article?
This was a randomized controlled trial with sound methodology. It focused solely on infants, a population that continues to be at high risk for failed lumbar punctures, in comparison to the other ultrasound assisted lumbar puncture studies to date.
Are there any limitations or flaws in the article?
This study was conducted at a single pediatric ED with a small number of sonographers who had varied ultrasound training. As such, it may not be generalizable to other settings, especially resource poor settings. Furthermore, although the study reported that success did not vary with experience level, nearly all lumbar punctures in both arms were performed by trainees (>97%) and the majority had little to zero experience.
What is the major takeaway message?
Ultrasound guided site marking improved infant lumbar puncture success rates with a number needed to treat of four. However, further studies are necessary to elucidate the generalizability of these findings and the impact on patient care (i.e. need for other procedures, exposure to antibiotics) and overall hospital resource utilization and cost.
Describe how this article should impact our practice:
Building on the advances in point of care ultrasonography and it’s increasing popularity and utilization in pediatrics, this article makes a strong case for ultrasound assisted lumbar punctures as an avenue for increasing procedure success rates, particularly in trainees. However, in the hands of more experienced providers and hospitals with less resources, the effects of this study are less clear. Further investigation into the generalizability of these results and a better outline of the necessary training and costs is warranted before a widespread commitment to changing standard practice.