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Ćwiek A, Kołodziej M. Ultrasound-Assisted Lumbar Punctures in Children: An Updated Systematic Review With Meta-Analysis. Hosp Pediatr 2024; 14:209-215. [PMID: 38356433 DOI: 10.1542/hpeds.2023-007480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
CONTEXT Lumbar puncture (LP) is a common procedure in children, but the rates of unsuccessful and traumatic LPs remain high. Point-of-care ultrasound (POCUS) has been proposed as a tool for improvement. OBJECTIVES Our aim was to systematically review current evidence on the usefulness of POCUS assisted LP in children. DATA SOURCES PubMed, Embase, and the CENTRAL were searched up to November 2022. STUDY SELECTION We searched for randomized control trials assessing the effectiveness of POCUS assisted LP in children. DATA EXTRACTION Data were extracted by 2 reviewers independently. RESULTS Seven randomized control trials involving 618 participants were included. Overall, the first attempt POCUS assisted LP was successful in 72% compared with 59.6% in the standard group, regardless of the definition used. The calculated risk difference was 13.0% (95% confidence interval [CI]: 3% to 23%) I2:53%, odds ratio: 2.00 (95% CI: 1.13 to 3.53), I2: 45% and risk ratio:1.21 (95% CI: 1.01 to 1.44) I2:64%. Additionally, fewer traumatic LPs occurred in the US-assisted group, with a risk difference of -12% (95% CI: -0.22 to -0.03), odds ratio: 0.45 (95% CI: 0.26 to 0.78) and risk ratio: 0.53 (95% CI: 0.35 to 0.79). POCUS did not extend the duration of LP procedure with mean difference: -1.11 (95% CI: -2.88 to 0.66). CONCLUSIONS POCUS improved the first attempt success rate and reduced the incidence of traumatic LPs compared with standard LP procedure in children. Therefore, if it is available, POCUS should be used routinely before every LP, especially when performed by less experienced physicians.
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Affiliation(s)
- Agata Ćwiek
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Maciej Kołodziej
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
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Abstract
BACKGROUND Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes. OBJECTIVES To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.99, 95% CI 0.88 to 1.12; RD 0.00, 95% CI -0.06 to 0.05; I2 = 47% and 46% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts as specified in this review. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position (I2 = not applicable; 2 studies; 1102 infants; high-certainty evidence; in one of the study median and IQR to report time to perform the lumbar puncture were 8 (5-13) and 8 (5-12) in the lateral and sitting position, respectively, I2 = not applicable; 1 study, 1082 infants; in the other study: mean difference 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review. AUTHORS' CONCLUSIONS When compared to sitting position, lateral decubitus position probably results in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts as specified in this review. Furthermore, infants in a sitting position likely experience less episodes of bradycardia and oxygen desaturation than in the lateral decubitus, and there may be little to no difference in episodes of apnea. Lateral decubitus position results in little to no difference in time to perform the lumbar puncture compared to sitting position. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.
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Affiliation(s)
- Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marcus Glenton Prescott
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital-Trondheim University Hospital, Trondheim, Norway
| | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
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Roehr CC, Marshall AS, Scrivens A, Sadarangani M, Williams R, Yong J, Linsell L, Chiocchia V, Bell JL, Stokes C, Santhanadass P, Nicoll I, Adams E, King A, Murray D, Bowler U, Stanbury K, Juszczak E. Techniques to increase lumbar puncture success in newborn babies: the NeoCLEAR RCT. Health Technol Assess 2023; 27:1-97. [PMID: 38149666 PMCID: PMC11017152 DOI: 10.3310/thjy0671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Background Lumbar puncture is an essential tool for diagnosing meningitis. Neonatal lumbar puncture, although frequently performed, has low success rates (50-60%). Standard technique includes lying infants on their side and removing the stylet 'late', that is, after the needle is thought to have entered the cerebrospinal fluid. Modifications to this technique include holding infants in the sitting position and removing the stylet 'early', that is, following transection of the skin. To the best of our knowledge, modified techniques have not previously been tested in adequately powered trials. Objectives The aim of the Neonatal Champagne Lumbar punctures Every time - An RCT (NeoCLEAR) trial was to compare two modifications to standard lumbar puncture technique, that is, use of the lying position rather than the sitting position and of 'early' rather than 'late' stylet removal, in terms of success rates and short-term clinical, resource and safety outcomes. Methods This was a multicentre 2 × 2 factorial pragmatic non-blinded randomised controlled trial. Infants requiring lumbar puncture (with a working weight ≥ 1000 g and corrected gestational age from 27+0 to 44+0 weeks), and whose parents provided written consent, were randomised by web-based allocation to lumbar puncture (1) in the sitting or lying position and (2) with early or late stylet removal. The trial was powered to detect a 10% absolute risk difference in the primary outcome, that is, the percentage of infants with a successful lumbar puncture (cerebrospinal fluid containing < 10,000 red cells/mm3). The primary outcome was analysed by modified intention to treat. Results Of 1082 infants randomised (sitting with early stylet removal, n = 275; sitting with late stylet removal, n = 271; lying with early stylet removal, n = 274; lying with late stylet removal, n = 262), 1076 were followed up until discharge. Most infants were term born (950/1076, 88.3%) and were aged < 3 days (936/1076, 87.0%) with a working weight > 2.5 kg (971/1076, 90.2%). Baseline characteristics were balanced across groups. In terms of the primary outcome, the sitting position was significantly more successful than lying [346/543 (63.7%) vs. 307/533 (57.6%), adjusted risk ratio 1.10 (95% confidence interval 1.01 to 1.21); p = 0.029; number needed to treat = 16 (95% confidence interval 9 to 134)]. There was no significant difference in the primary outcome between early stylet removal and late stylet removal [338/545 (62.0%) vs. 315/531 (59.3%), adjusted risk ratio 1.04 (95% confidence interval 0.94 to 1.15); p = 0.447]. Resource consumption was similar in all groups, and all techniques were well tolerated and safe. Limitations This trial predominantly recruited term-born infants who were < 3 days old, with working weights > 2.5 kg. The impact of practitioners' seniority and previous experience of different lumbar puncture techniques was not investigated. Limited data on resource use were captured, and parent/practitioner preferences were not assessed. Conclusion Lumbar puncture success rate was higher with infants in the sitting position but was not affected by timing of stylet removal. Lumbar puncture is a safe, well-tolerated and simple technique without additional cost, and is easily learned and applied. The results support a paradigm shift towards sitting technique as the standard position for neonatal lumbar puncture, especially for term-born infants during the first 3 days of life. Future work The superiority of the sitting lumbar puncture technique should be tested in larger populations of premature infants, in those aged > 3 days and outside neonatal care settings. The effect of operators' previous practice and the impact on family experience also require further investigation, alongside in-depth analyses of healthcare resource utilisation. Future studies should also investigate other factors affecting lumbar puncture success, including further modifications to standard technique. Trial registration This trial is registered as ISRCTN14040914 and as Integrated Research Application System registration 223737. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/188/106) and is published in full in Health Technology Assessment; Vol. 27, No. 33. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Charles C Roehr
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Sj Marshall
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Alexandra Scrivens
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Rachel Williams
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jean Yong
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Virginia Chiocchia
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jennifer L Bell
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Caz Stokes
- Support for the Sick Newborn And their Parents (SSNAP) Charity, John Radcliffe Hospital, Oxford, UK
| | - Patricia Santhanadass
- Support for the Sick Newborn And their Parents (SSNAP) Charity, John Radcliffe Hospital, Oxford, UK
| | - Ian Nicoll
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Andrew King
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Murray
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ursula Bowler
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kayleigh Stanbury
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Edmund Juszczak
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
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Pessano S, Bruschettini M, Prescott MG, Romantsik O. Positioning for lumbar puncture in newborn infants. Cochrane Database Syst Rev 2023; 10:CD015592. [PMID: 37870133 PMCID: PMC10591282 DOI: 10.1002/14651858.cd015592.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes. OBJECTIVES To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.93, 95% CI 0.85 to 1.02; RD -0.04, 95% CI -0.09 to 0.01; I2 = 70% and 72% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I2 = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I2 = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). The evidence is very uncertain regarding the effect of lateral decubitus position on time to perform the lumbar puncture (MD 2.00, 95% CI -4.98 to 8.98; I2 = not applicable; 1 study, 20 infants, very low-certainty evidence). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I2 = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I2 = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review. AUTHORS' CONCLUSIONS When compared to sitting position, lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts. Furthermore, infants in a lateral decubitus position likely experience more episodes of bradycardia and oxygen desaturation, and there may be little to no difference in episodes of apnea. The evidence is very uncertain regarding time to perform lumbar puncture. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.
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Affiliation(s)
- Sara Pessano
- Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Matteo Bruschettini
- Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marcus Glenton Prescott
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital-Trondheim University Hospital, Trondheim, Norway
| | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
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Zubi ZBH, Abdullah AFB, Helmi MABM, Hasan TH, Ramli N, Ali AAABM, Mohamed MAS. Indications, Measurements, and Complications of Ten Essential Neonatal Procedures. Int J Pediatr 2023; 2023:3241607. [PMID: 37705709 PMCID: PMC10497369 DOI: 10.1155/2023/3241607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/11/2023] [Accepted: 07/21/2023] [Indexed: 09/15/2023] Open
Abstract
About 10% of newborns require some degree of assistance to begin their breathing, and 1% necessitates extensive resuscitation. Sick neonates are exposed to a number of invasive life-saving procedures as part of their management, either for investigation or for treatment. In order to support the neonates with the maximum possible benefits and reduce iatrogenic morbidity, health-care providers performing these procedures must be familiar with their indications, measurements, and potential complications. Hence, the aim of this review is to summarise ten of the main neonatal intensive care procedures with highlighting of their indications, measurements, and complications. They include the umbilical venous and arterial catheterizations and the intraosseous line which represent the principal postnatal emergency vascular accesses; the peripherally inserted central catheter for long-term venous access; the endotracheal tube and laryngeal mask airway for airway control and ventilation; chest tube for drainage of air and fluid from the thorax; and the nasogastric/orogastric tube for enteral feeding. Furthermore, lumber puncture and heel stick were included in this review as very important and frequently performed diagnostic procedures in the neonatal intensive care unit.
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Affiliation(s)
- Zainab Bubakr Hamad Zubi
- Department of Paediatrics, Sultan Ahmad Shah Medical Centre, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Ahmad Fadzil Bin Abdullah
- Department of Paediatrics, Kulliyyah of Medicine, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Muhd Alwi Bin Muhd Helmi
- Department of Paediatrics, Kulliyyah of Medicine, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Taufiq Hidayat Hasan
- Department of Paediatrics, Kulliyyah of Medicine, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Noraida Ramli
- Department of Paediatrics, School of Medical Sciences, University Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | | | - Mossad Abdelhak Shaban Mohamed
- Department of Paediatrics, Kulliyyah of Medicine, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
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Sievänen H, Kari J, Aarnivala H, Becker S, Huurre A, Långström S, Palmu S. Success and complications in lumbar punctures of pediatric patients with leukemia: a study protocol for a randomized clinical crossover trial of a bioimpedance needle system versus conventional procedure. Trials 2023; 24:464. [PMID: 37475006 PMCID: PMC10360266 DOI: 10.1186/s13063-023-07498-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 07/06/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Acute lymphoblastic leukemia (ALL) is the most common malignancy diagnosed in children. At present, the long-term survival from pediatric ALL is well over 90%. However, the probability of event-free survival is reduced if the lumbar puncture (LP) procedures at the beginning of the patient's intrathecal therapy cause blood leakage into the spinal canal and blast cells contaminate the cerebrospinal fluid. According to the literature, such traumatic LP procedures concern one out of five pediatric patients with ALL. Recently, a novel medical device measuring the tissue bioimpedance at the tip of a spinal needle was found feasible in pediatric patients with ALL. The LP procedure was successful at the first attempt in 80% of procedures, and the incidence of traumatic LPs was then 11%. The purpose of the present study is to compare the bioimpedance spinal needle system with the standard clinical practice resting on a conventional spinal needle and investigate its efficacy in clinical practice. METHODS The study is a multicenter, randomized, two-arm crossover noninferiority trial of pediatric hemato-oncology patients that will be conducted within the usual clinical workflow. Patients' LP procedures will be performed alternately either with the IQ-Tip system (study arm A) or a conventional Quincke-type 22G spinal needle (study arm B). For each enrolled patient, the order of procedures is randomly assigned either as ABAB or BABA. The total number of LP procedures will be at least 300, and the number of procedures per patient between two and four. After each study LP procedure, the performance will be recorded immediately, and 1-week diary-based and 4-week record-based follow-ups on symptoms, complications, and adverse events will be conducted thereafter. The main outcomes are the incidence of traumatic LP, first puncture success rate, and incidence of post-dural puncture headache. DISCUSSION The present study will provide sound scientific evidence on the clinical benefit, performance, and safety of the novel bioimpedance spinal needle compared with the standard clinical practice of using conventional spinal needles in the LP procedures of pediatric patients with leukemia. TRIAL REGISTRATION ISRCTN ISRCTN16161453. Registered on 8 July 2022.
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Affiliation(s)
| | | | - Henri Aarnivala
- Department of Pediatric Hematology and Oncology, Oulu University Hospital, Oulu, Finland
| | - Stefan Becker
- Department of Pediatric Hematology and Oncology, Kuopio University Hospital, Kuopio, Finland
| | - Anu Huurre
- Department of Pediatric and Adolescent Hematology and Oncology, Turku University Hospital, Turku, Finland
| | - Satu Långström
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Sauli Palmu
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland.
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7
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Bedetti L, Miselli F, Minotti C, Latorre G, Loprieno S, Foglianese A, Laforgia N, Perrone B, Ciccia M, Capretti MG, Giugno C, Rizzo V, Merazzi D, Fanaro S, Taurino L, Pulvirenti RM, Orlandini S, Auriti C, Haass C, Ligi L, Vellani G, Tzialla C, Tuoni C, Santori D, China M, Baroni L, Nider S, Visintini F, Decembrino L, Nicolini G, Creti R, Pellacani E, Dondi A, Lanari M, Benenati B, Biasucci G, Gambini L, Lugli L, Berardi A. Lumbar Puncture and Meningitis in Infants with Proven Early- or Late-Onset Sepsis: An Italian Prospective Multicenter Observational Study. Microorganisms 2023; 11:1546. [PMID: 37375048 DOI: 10.3390/microorganisms11061546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Background: To evaluate the rates of lumbar puncture (LP) in infants with culture-proven sepsis. Study design: We prospectively enrolled 400 infants with early- or late-onset sepsis due to Group B streptococcus (GBS) or Eschericha coli, diagnosed within 90 days of life. Rates of LP and potential variables associated with LP performance were evaluated. Moreover, cerebrospinal fluid (CSF) characteristics and results of the molecular analysis were investigated. Results: LP was performed in 228/400 (57.0%) infants; 123/228 LPs (53.9%) were performed after antibiotic initiation, hampering the ability to identify the pathogen in the CSF culture. However, polymerase chain reaction increased the probability of positive results of CSF analysis compared to microbiological culture (28/79, 35.4% vs. 14/79, 17.7%, p = 0.001). Severe clinical presentation and GBS infection were associated with higher LP rates. The rate of meningitis was 28.5% (65/228). Conclusions: Rates of LP are low in culture-proven neonatal sepsis and antibiotics are frequently given before LP is carried out. Thus meningitis may be underestimated, and the chances of giving an effective therapy to the newborn are reduced. LP should be performed before the start of antibiotics when there is a clinical suspicion of infection.
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Affiliation(s)
- Luca Bedetti
- Neonatal Intensive Care Unit, University Hospital of Modena, 41224 Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 21124 Modena, Italy
| | - Francesca Miselli
- Neonatal Intensive Care Unit, University Hospital of Modena, 41224 Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 21124 Modena, Italy
| | - Chiara Minotti
- Neonatal Intensive Care Unit, University Hospital of Modena, 41224 Modena, Italy
| | - Giuseppe Latorre
- Neonatal Intensive Care Unit, Ecclesiastical General Hospital F. Miulli, 70021 Acquaviva delle Fonti, Italy
| | - Sabrina Loprieno
- Department of Biomedical Science and Human Oncology (DIMO), Neonatal Intensive Care Unit, University Hospital of Bari "Aldo Moro", 70124 Bari, Italy
| | - Alessandra Foglianese
- Department of Biomedical Science and Human Oncology (DIMO), Neonatal Intensive Care Unit, University Hospital of Bari "Aldo Moro", 70124 Bari, Italy
| | - Nicola Laforgia
- Department of Biomedical Science and Human Oncology (DIMO), Neonatal Intensive Care Unit, University Hospital of Bari "Aldo Moro", 70124 Bari, Italy
| | - Barbara Perrone
- Neonatal Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Matilde Ciccia
- Neonatal Intensive Care Unit, Women's and Children's Health Department, Maggiore Hospital, 40133 Bologna, Italy
| | - Maria Grazia Capretti
- Neonatal Intensive Care Unit, Women's and Children's Health Department, S. Orsola-Malpighi Hospital, 40138 Bologna, Italy
| | - Chiara Giugno
- Pediatric Unit, Ospedale B. Ramazzini, 41012 Carpi, Italy
| | - Vittoria Rizzo
- Neonatal Intensive Care Unit, Bufalini Hospital, 47521 Cesena, Italy
| | - Daniele Merazzi
- Division of Neonatology, "Valduce" Hospital, 22100 Como, Italy
| | - Silvia Fanaro
- Department of Medical Sciences, Pediatric Section, University Hospital, 44124 Ferrara, Italy
| | - Lucia Taurino
- Neonatal Intensive Care Unit, Ospedali Riuniti, 71122 Foggia, Italy
| | - Rita Maria Pulvirenti
- Pediatric and Neonatal Unit, Morgagni-Pierantoni Hospital of Forlì, 47121 Forli, Italy
| | - Silvia Orlandini
- Neonatal Intensive Care Unit, Carlo Poma Hospital, 46100 Mantova, Italy
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, "Bambino Gesù" Children's Hospital IRCCS, 00165 Rome, Italy
| | - Cristina Haass
- Neonatal Intensive Unit, San Pietro-Fatebenefratelli Hospital, 00168 Rome, Italy
| | - Laura Ligi
- Neonatal Intensive Unit, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Giulia Vellani
- Neonatal Intensive Unit, ARNAS Civico-Di Cristina-Benfratelli, 90127 Palermo, Italy
| | - Chryssoula Tzialla
- Neonatal and Pediatric Unit, Polo Ospedaliero Oltrepò, ASST Pavia, 27100 Pavia, Italy
| | - Cristina Tuoni
- Neonatology and Neonatal Intensive Care Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, 56124 Pisa, Italy
| | - Daniele Santori
- Pediatric and Neonatal Unit, Azienda Ospedaliera Santa Maria degli Angeli, 33170 Pordenone, Italy
| | | | - Lorenza Baroni
- Neonatal Intensive Care Unit, Santa Maria Nuova Hospital, 42123 Reggio Emilia, Italy
| | - Silvia Nider
- Neonatal Intensive Care Unit, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | | | - Lidia Decembrino
- ASST Pavia, Unità Operativa di Pediatria e Nido, Ospedale Civile, 27029 Vigevano, Italy
| | | | - Roberta Creti
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy
| | - Elena Pellacani
- Residency in Pediatrics, Departmento of Medical and Surgical Science, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Arianna Dondi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, 40138 Bologna, Italy
| | - Belinda Benenati
- Pediatric and Neonatal Unit, Women's and Children's Health Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Giacomo Biasucci
- Pediatric and Neonatal Unit, Women's and Children's Health Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Lucia Gambini
- Neonatal Intensive Care Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Licia Lugli
- Neonatal Intensive Care Unit, University Hospital of Modena, 41224 Modena, Italy
| | - Alberto Berardi
- Neonatal Intensive Care Unit, University Hospital of Modena, 41224 Modena, Italy
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Schlapbach LJ, Peters MJ. Pragmatic trials for critical illness in neonates and children. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:78-79. [PMID: 36460016 DOI: 10.1016/s2352-4642(22)00345-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Luregn J Schlapbach
- Department of Intensive Care and Neontaology, and Children's Research Center, University Children's Hospital Zurich, CH-8032 Zurich, Switzerland; Child Health Research Centre, The University of Queensland, Brisbane, Australia.
| | - Mark J Peters
- University College London Great Ormond Street Institute of Child Health, London, UK; Paediatric Intensive Care Unit, Great Ormond Street NHS Foundation Trust, London, UK
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