Postdural puncture headache in pediatric oncology patients

Bioimpedance spinal needle provides high success and low complication rate in lumbar punctures of pediatric patients with acute lymphoblastic leukemia

In this prospective single-arm study of 50 pediatric patients with acute lymphoblastic leukemia (ALL), we evaluated the clinical performance of a novel bioimpedance spinal needle system in 152 intrathecal treatment lumbar punctures (LP) of these patients. The system detects in real-time when the needle tip reaches the cerebrospinal fluid (CSF) in the spinal canal. The success was defined as getting a CSF sample and/or administering the intrathecal treatment with one needle insertion. Incidence of traumatic LP (TLP) was defined as ≥ 10 erythrocytes/µL of CSF. Post-procedural complications were monitored with a one-week diary and one-month register follow-up. The success of the first attempt was 79.5%, with the CSF detection sensitivity of 86.1%. The incidence of TLP was 17.3%. A successful first attempt was associated with a significantly lower incidence of TLP (10% vs 40%, p = 0.0015). During the week after the procedure, the incidence of post-dural puncture headache was 6%. During the follow-up, no major complications were observed. In conclusion, the novel bioimpedance spinal needle system achieved a high success rate and low incidence of TLP and other complications in pediatric patients with ALL in a real-world clinical setting, indicating clinical utility for this system in pediatric hemato-oncology.

Parental Attitudes and Knowledge About Lumbar Puncture in Children

OBJECTIVES

Lumbar puncture (LP) is fundamental for diagnosis and treatment; however, some parents do not provide consent for their children to undergo the procedure, which can make diagnosis and determination of the optimal treatment difficult. The present study aimed to describe the level of knowledge and attitudes toward LP of parents whose children were scheduled to undergo the procedure.

METHODS

A prospective cross-sectional descriptive study of a convenience sample of parents of 84 children aged 2 months to 17 years scheduled for LP at a single academic children's hospital between 2015 and 2017. Parents were administered a written survey and interviewed by a physician other than the person who did the LP. Data on parental level of knowledge and attitudes regarding LP, in addition to reasons for refusal, were collected.The parents of 84 patients scheduled for LP due to various indications were administered a face-to-face survey interview. The survey was used to collect parental demographic data, as well as opinions and knowledge about LP and postinterventional complications.

RESULTS

The mean age of the 84 patients (57% male and 43% female) was 6.4 ± 5.17 years. Lumbar puncture was planned for the presumptive diagnosis of neurological disease in 45.25% of the patients, central nervous system infection in 45.25%, and acute encephalopathy in 9.5%. Among the parents, 65% (n = 55) had no knowledge or attitude about LP prior to the survey interview. The most common parental concern related to LP was paralysis (25%), followed by infertility (2%), mental retardation (1%), and disease progression (1%). Only 4.7% of the parents did not provide consent for their child to undergo LP.

CONCLUSIONS

We found that most parents had little knowledge about LP, and the most common parental concern was paralysis. Despite this, in our study, only 5% of parents did not consent to LP.

Preventing Post-Lumbar Puncture Headache

Post-lumbar puncture headache is the main adverse event from lumbar puncture and occurs in 3.5% to 33% of patients, causing functional and socio-professional disability. We searched the post-lumbar puncture headache literature and, based on this review and personal expertise, identified and addressed 19 frequently asked questions regarding post-lumbar puncture headache risk factors and prevention. Among the nonmodifiable factors, older age is associated with a lower incidence of post-lumbar puncture headache, while female sex, lower body mass index, and history of headache might be associated with increased risk. The use of atraumatic, noncutting needles is the most effective intervention for post-lumbar puncture headache prevention. These needles are not more difficult to use than cutting needles. Other commonly recommended measures (eg, fluid supplementation, caffeine) appear unhelpful, and some (eg, bed rest) may worsen post-lumbar puncture headache.

Progress and promise of antisense oligonucleotide therapeutics for central nervous system diseases

Antisense oligonucleotide (ASO) drugs are an emerging class of therapeutics that have recently demonstrated progress and promise to treat diseases of the central nervous system (CNS). ASOs for a variety of targets and mechanisms are currently being investigated in clinical trials and pre-clinically for a number of CNS diseases. This review examines the available data regarding central ASO delivery, distribution, pharmacokinetics, pharmacodynamics and therapeutic opportunities. This article is part of the Special Issue entitled "Beyond small molecules for neurological disorders".

Prevention and Management of Post–Lumbar Puncture Headache in Pediatric Oncology Patients

Pediatric oncology patients are at risk for developing a headache after they undergo a lumbar puncture for diagnostic or therapeutic purposes. These headaches are likely due to leakage of cerebrospinal fluid at the puncture site. While usually mild and self-limited, some headaches may be persistent and severe, adding to the distress of these young patients. In the past 10 years, refinements in lumbar needle size and shape as well as procedural techniques have reduced the tissue trauma that predisposes patients to headache. A number of interventions, such as bed rest, hydration, caffeine administration, and epidural blood patching, have been suggested to prevent and relieve the headaches that follow lumbar punctures. This article outlines the pathophysiology and incidence of headaches related to lumbar punctures in the pediatric oncology setting and reviews the evidence from research trials to suggest which interventions clinicians should adopt into their practice to minimize this complication of lumbar punctures.

Results from a phase 1 study of nusinersen (ISIS-SMN(Rx)) in children with spinal muscular atrophy

Objective:

To examine safety, tolerability, pharmacokinetics, and preliminary clinical efficacy of intrathecal nusinersen (previously ISIS-SMN_Rx), an antisense oligonucleotide designed to alter splicing of SMN2 mRNA, in patients with childhood spinal muscular atrophy (SMA).

Methods:

Nusinersen was delivered by intrathecal injection to medically stable patients with type 2 and type 3 SMA aged 2–14 years in an open-label phase 1 study and its long-term extension. Four ascending single-dose levels (1, 3, 6, and 9 mg) were examined in cohorts of 6–10 participants. Participants were monitored for safety and tolerability, and CSF and plasma pharmacokinetics were measured. Exploratory efficacy endpoints included the Hammersmith Functional Motor Scale Expanded (HFMSE) and Pediatric Quality of Life Inventory.

Results:

A total of 28 participants enrolled in the study (n = 6 in first 3 dose cohorts; n = 10 in the 9-mg cohort). Intrathecal nusinersen was well-tolerated with no safety/tolerability concerns identified. Plasma and CSF drug levels were dose-dependent, consistent with preclinical data. Extended pharmacokinetics indicated a prolonged CSF drug half-life of 4–6 months after initial clearance. A significant increase in HFMSE scores was observed at the 9-mg dose at 3 months postdose (3.1 points; p = 0.016), which was further increased 9–14 months postdose (5.8 points; p = 0.008) during the extension study.

Conclusions:

Results from this study support continued development of nusinersen for treatment of SMA.

Classification of evidence:

This study provides Class IV evidence that in children with SMA, intrathecal nusinersen is not associated with safety or tolerability concerns.

Evidence-Based Practice Recommendations to Prevent/Manage Post-Lumbar Puncture Headaches in Pediatric Patients Receiving Intrathecal Chemotherapy

Post-lumbar puncture headaches (PLPHs) are a known complication of lumbar puncture procedures. Children undergoing treatment for cancer often undergo multiple lumbar punctures, placing them at increased risk for PLPHs. There are currently no guidelines for the prevention or management of PLPHs in children. A team was therefore assembled to conduct a systematic review of the evidence in relationship to PLPHs in the pediatric population. Clinical questions were developed and used to guide the literature review. Twenty-four articles were deemed appropriate for use and were evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Based on the review of evidence, strong recommendations are made for the use of smaller needle sizes and for the use of pencil point needles during lumbar puncture procedures. Weak recommendations are made for needle orientation and positioning following the procedure as well as for interventions used to treat PLPHs once they occur. There is a need for additional, pediatric-specific studies to further examine the issue of PLPH prevention and treatment.

Headache after lumbar puncture: randomised crossover trial of 22-gauge versus 25-gauge needles

OBJECTIVES

To compare the frequency of headache and the procedure time following lumbar puncture (LP) using a 25-gauge needle compared to a 22-gauge needle.

DESIGN

4-period crossover blinded randomised controlled trial.

SETTING

Oncology unit, Royal Children's Hospital, Melbourne.

PATIENTS

Children aged 4-15 years at enrolment having LPs as part of their treatment for leukaemia.

INTERVENTIONS

Each child was allocated a random sequence of four LPs, two with a 22-gauge and two with a 25-gauge needle.

OUTCOME MEASURES

The presence of post-LP headache. Secondary outcomes included the presence of any headache, procedure time and impact of headache on the family.

RESULTS

Data on 341 procedures in 93 randomised children were analysed. There was little difference in the incidence of post-LP headache between the two needle sizes (22-gauge 7.2%, 95% CI 3.8 to 12.2; 25-gauge 4.6%, 95% CI 2.0 to 8.9, p=0.3) or in the incidence of any headache (22-gauge 18% 95% CI 12.5 to 24.6; 25-gauge 15%, 95% CI 10.0 to 21.1, p=0.4). Use of the 25-gauge needle was associated with longer procedure times. The incidence of post-LP headache showed little evidence of an age effect (OR =1.1, 95% CI 0.98 to 1.3) and was higher in girls than in boys (11% vs 3%, respectively, OR=3.3, 95% CI 1.3 to 8.4, p=0.014). Fifty-five per cent of families with a child with a post-LP headache assessed the overall functional impact as moderate or severe.

CONCLUSIONS

There was little difference in the occurrence of post-LP headache or any headache between procedures carried out using the 22-gauge or 25-gauge needles. Depending on the circumstances of the procedure and the experience of the operator, either gauge may be appropriate for an LP in a child.

[Chronic pain and regional anesthesia in children]

Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patient's blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety.

Successful management of a thoracic cerebrospinal fluid cutaneous fistula in a two year old child using a thoracic epidural blood patch

A case of persistent thoracic cerebrospinal fluid cutaneous fistula in a toddler following radiographically confirmed epidural catheter placement is reported. Treatment of the fistula with a thoracic epidural blood patch was successful.

A guide to diagnoses, indications, and contraindications for interventions in pediatric chronic pain

Although the painful conditions in children and young adults do not involve a broad spectrum of disorders, the treatment itself may pose a challenge. Taking care of psychosocial factors is equally important as taking care of physical aspects. Our simple suggestion is to start with basics and advance to more complex treatments if needed. Please review Figure 2 for suggested treatment algorithms.

[Do paediatricians perform lumbar puncture correctly? Review of recommendations and analysis the technique in Spain]

INTRODUCTION

Lumbar puncture (LP) is a commonly performed procedure in paediatrics. Performing this technique properly can avoid the most common associated complications.

OBJECTIVE

To assess whether paediatricians and paediatric residents in Spain follow current recommendations for the LP technique.

MATERIAL AND METHODS

A cross-sectional study was conducted by sending a questionnaire by mail through the Spanish Society of Paediatric Emergencies, collecting demographic information and responses to multiple choice questions about LP technique.

RESULTS

A total of 206 questionnaires were analysed, of which 143 (69.5%) were answered by paediatricians, and 63 (30.5%) by paediatric residents. The majority (128; 62.1%) of physicians did not allow parents to be present during LP, 198 (96.1%) routinely use analgesia and sedation; 84 (42%) only used local anaesthesia. The majority of respondents used standard Quincke needles (126; 62.7%). The bevel was correctly positioned when puncturing the dura mater by 22 residents (36.1%) and 21 paediatricians (15.1%), a variation that was statistically significant (P=.001). For neonatal lumbar punctures, 63 paediatricians (46%) and 19 paediatric residents used a butterfly needle which did not contain a stylet, and this difference was also statistically significant (P=.035). Of those surveyed, 190 (92.2%) re-inserted the stylet when re-orientating the needle, and 186 (93%) re-oriented this when removing it. The recommendation of bed rest was made by 195 (94.7%) physicians.

CONCLUSIONS

The majority of paediatricians orient the bevel wrongly when inserting the needle during LP, and still use "butterfly" needles in newborns, despite warnings to the contrary. Paediatric residents and less experienced paediatricians follow the recommendations more frequently.

Neurologic sequelae of brain tumors in children

Neurologic signs and symptoms are often the initial presenting features of a primary brain tumor and may also emerge during the course of therapy or as late effects of the tumor and its treatment. Variables that influence the development of such neurologic complications include the type, size, and location of the tumor, the patient's age at diagnosis, and the treatment modalities used. Heightened surveillance and improved neuroimaging modalities have been instrumental in detecting and addressing such complications, which are often not appreciated until many years after completion of therapy. As current brain tumor therapies are continually refined and newer targeted therapies are developed, it will be important for future cooperative group studies to include systematic assessments to determine the incidence of neurologic complications and to provide a framework for the development of novel strategies for prevention and intervention.

Incidence of postdural puncture headache and backache following diagnostic/therapeutic lumbar puncture using a 22G cutting spinal needle, and after introduction of a 25G pencil point spinal needle

BACKGROUND

Postdural puncture headache (PDPH) after lumbar puncture (LP) is as common in children as adults. 22G needles are routinely used in adults and children for diagnostic/therapeutic LP, in contrast to 25G or less as standard for spinal anesthesia. We sought to identify incidence of PDPH and backache in oncology children undergoing LP at Royal Marsden Hospital, and whether this could be reduced by a change from 22G to 25G pencil point needle.

METHODS

Symptom questionnaires were given to parents for completion 7 days following LP, and incidence of side effects ascertained. The standard needle was a 22G Quincke. A 25G pencil point spinal needle was subsequently introduced and incidence of side effects reaudited. Number of attempts with the pencil point needle was documented.

RESULTS

Fifty-six of 83 questionnaires were completed for the 22G Quincke (67%). Incidence of headache was 33%, with 11% classified as PDPH (6 children, 2 > 7 days). Nausea/vomiting occurred in 25% and backache in 11%; 43 of 79 questionnaires were completed for the 25G pencil point needle (54%). Incidence of headache was 30% with 7% classified as PDPH (3 children, none >7 days). Nausea/vomiting occurred in 23%, and backache in none. Seventy percentage of needle insertions by pediatricians were successful on first attempt, 89% on second, and 100% on third.

CONCLUSIONS

We have confirmed a significant incidence of PDPH in oncology patients and suggest that a 25G pencil point needle can be used successfully for diagnostic/therapeutic LP, with significantly reduced incidence of back pain, and a small tendency towards a shorter duration of PDPH symptoms.

Effect of the introduction of a lumbar-puncture sticker and teaching manikin on junior staff documentation and performance of paediatric lumbar punctures

BACKGROUND

Performing a lumbar puncture in an unwell child can cause anxiety in both the parent and the junior doctor. There is increasing evidence of post-lumbar-puncture complications in this age group.

AIMS

To improve the documentation, consent for and technical performance of paediatric lumbar punctures to 100% of the required standard within 3 months.

SETTING

The paediatric emergency department of a the Royal North Shore Hospital (University of Sydney, Sydney, Australia).

PARTICIPANTS

Paediatric emergency staff, including residents, registrars and consultants.

METHODS

Medical records of 40 consecutive children who had undergone a lumbar puncture in the 6 months before the introduction of the lumbar-puncture proforma were reviewed. After introduction of the proforma, the records of 25 consecutive patients were reviewed to assess changes in the outcome measures. Before introduction of the proforma, junior medical staff were instructed in the procedure using specialised lumbar puncture manikins (Baby Stap; Laerdel, USA).

RESULTS

Before introduction of the proforma, the median number of documented indicators was 4, out of a maximum of 12. There was almost no documentation of parental consent, patient complications and analgesia. Introduction of the proforma resulted in a highly marked increase to a median of 12 documented indicators per patient (p<0.01, 95% confidence interval 6 to 8).

CONCLUSIONS

The introduction of a lumbar-puncture proforma and formal teaching sessions using a paediatric manikin led to a marked improvement in the documentation of paediatric lumbar-punctures. Lumbar-punctures can be performed only by accredited medical officers who have achieved competency on the lumbar-puncture teaching manikin.

Les céphalées après ponction lombaire en pédiatrie générale : étude prospective multicentrique

PURPOSE

To investigate the frequency of post lumbar puncture headaches (PLPH) after diagnostic lumbar puncture (LP) and to search for influence factors.

PATIENTS AND METHODS

Conducted over 6 months into 8 paediatric services, the study concerned 2 to 15 years old children. The LP technic (cannula gauge, bevel orientation, child position, reinsertion of the stylet) was standardised. For each child questionnaires were filled with the parents 3 and 8 days after LP for inquiring headaches, postural characteristics, length and clinical consequences.

RESULTS

Among 84 charts, 71 were exploitable. PLPH were observed in 25% of children. The mean duration was 5.9 days, mean bed rest was 1.4 day and mean antalgic treatment 1.7 day. The frequency of PLPH was not significantly influenced by age and sex, neither by the qualification of the physician performing the LP. The frequency was significantly lower when LP execution was easy (19.6 vs. 46.7%; P < 0.05), and when the child had viral meningitis (8 vs. 34.8%; P < 0.05).

CONCLUSION

We have found a more important frequency of PLPH than in previous paediatric studies. Clinical consequences justify other researches to precise influence factors and reduce the frequency of this complication.

Prospective evaluation of clinical and laboratory effects of intrathecal chemotherapy on children with acute leukemia

The objective of this prospective 18-month study was to evaluate the clinical and laboratory effects of repeated intrathecal injections of chemotherapy in children with acute leukemia. All procedures were performed under general anesthesia, and complications were prospectively recorded. Laboratory measurements included lumbar puncture opening pressure, cerebrospinal fluid (CSF) chemistry, and cell count and morphology. Central venous pressure and ophthalmologic examinations were also performed. Forty-seven children underwent 247 intrathecal injections of chemotherapy. Adverse effects (13.7% of the procedures) included nausea and vomiting, back pain, and headache. One child each had transient cauda equina syndrome, transient communicating hydrocephalus, and persistent sacral plexus injury. The mean lumbar puncture opening pressure was significantly higher after intrathecal therapy than before (22 +/- 8 vs. 15 +/- 9 cm H2O, P = 0.02) and higher than reported in age-matched children without leukemia. All CSF chemistries, cell count, and morphology were normal. The overall incidence of complications was 13.7%. Most were mild and resolved quickly, but significant neurologic complications did occur. Lumbar puncture opening pressure was significantly higher in children with acute leukemia after intrathecal chemotherapy.

Spinal anaesthesia in paediatric patients

PURPOSE OF REVIEW

Spinal anaesthesia has seldom been employed in paediatric patients. Its use has been suggested mainly in former preterm newborns and infants who are known to be exposed to high perioperative apnoea risk. There is currently some evidence that spinal anaesthesia could be considered as an equal alternative to general anaesthesia as it is in adults.

RECENT FINDINGS

New drugs and adjuvants recently introduced in clinical practice, more-detailed knowledge of spread anaesthetic modalities and larger databases, now available, could today make paediatric spinal anaesthesia a more suitable technique for many anaesthetists.

SUMMARY

We will review recent literature focusing the latest techniques, drugs, dosages, and complications in order to define the limits and advantages of employing spinal anaesthesia in all paediatric ages, in routine and emergency surgery.

Headache and backache after lumbar puncture in children and adolescents: a prospective study

OBJECTIVE

After lumbar puncture, many adults develop headaches or backaches. Postpuncture complaints are believed to be rare in children and adolescents, but their exact incidence is unclear because there is a paucity of data derived from general pediatric patients. In a prospective study of general pediatric and neuropediatric patients, we investigated the frequency of postlumbar puncture headaches or backaches and factors that might influence their occurrence.

METHODS

Conducted over 12 months, the prospective study included 112 patients aged 2 to 16 years. We evaluated them for factors that might influence the rate of postpuncture complaints: age, gender, use of local anesthesia, cannula gauge, bevel orientation, number of puncture attempts, volume of cerebrospinal fluid (CSF) aspirated, and cell count in CSF.

RESULTS

Twenty-seven percent of the patients experienced headaches (positional headache in 9%), and 40% developed backache. Frequency of complaints increased in relation to patients' age. In older children, girls reported complaints more frequently than did boys. Patients with higher cell counts in CSF had more frequent headaches than did patients without pleocytosis. Cannula gauge or bevel orientation did not influence outcome.

CONCLUSION

The frequency of positional and nonpositional headaches after lumbar puncture is lower in children than in adults. Backaches contribute significantly to postpuncture morbidity. With puberty, the incidences of postpuncture complaints increase, and girls start to become more prone to develop postpuncture headaches. Recommendations regarding cannula gauge or bevel orientation that derive from studies in adults are not confirmed for children.

Spinal anaesthesia in paediatrics

The use of spinal anaesthesia in children has been primarily limited to situations in which general anaesthesia was considered to pose an excessive risk. The ex-premature infant and the neurologically impaired child account for the majority of spinal anaesthetics used today. Spinal anaesthesia, compared with general anaesthesia, in the ex-premature infant undergoing inguinal hernia repair has decreased postoperative respiratory complications (e.g. apnoeic events, prolonged mechanical ventilation). Hyperbaric tetracaine and bupivacaine solutions are the local anaesthetics of choice. Haemodynamic stability is well preserved in neonates having spinal anaesthesia. Advances in spinal needle design have decreased the incidence of postdural puncture headache (PDPH). Catastrophic events have occurred with neuraxial techniques. Care must be taken in evaluating the relative risks of anaesthetic approaches in infants and children.

Considerations for anaesthesia in children with haematological malignancy undergoing short procedures

As a result of increased use of risk-directed treatment regimes, there is a regular requirement for short-lasting but painful procedures to be performed on children to aid in diagnosis or treatment. The aim of any anaesthetic technique is to provide analgesia and amnesia with minimal side-effects and early return to former activity levels. We review the implications of haematological malignancy in children with regard to anaesthesia and the consequences arising from both the disease and ensuing treatment. We outline some of the current anaesthetic techniques in use and review the advantages and disadvantages of each.

Post-dural puncture headaches in children. A literature review

Post-dural puncture headache (PDPH) is a well recognised complication of spinal and epidural anaesthesia. It can also occur after diagnostic or therapeutic lumbar puncture. Few cases have been reported in children. We reviewed the literature regarding definition, aetiology, incidence, risk factors, prevention and treatment, in order to provide some recommendations. Significant factors include age, gender, needle diameter, needle tip design, orientation of the tip during puncture, previous PDPH, history of migraine and repeated attempts to achieve puncture. There is no evidence for the use of increased fluids or bed rest to prevent PDPH. Once the diagnosis is made, conservative therapy is recommended for 48 h. Persistent PDPH can be treated in several ways; an epidural blood patch is one of the most effective methods.

CONCLUSION

occurrence of post-dural puncture headache after lumbar puncture in children is rare. There are conflicting data about risk factors, prevention and treatment.

Management of postdural puncture headache with epidural blood patch in children

BACKGROUND

Until the last decade, it was believed that postdural puncture headache (PDPH) was an uncommon complaint in children, but recent studies indicate that young children may develop PDPH after spinal puncture. When the symptoms are severe and are not relieved within a few days with analgesics, forced hydration and bed rest, then epidural blood patch (EBP) might be performed.

METHODS

In this retrospective survey, we analysed EBP performed in Kuopio University Hospital between the years 1995 and 2000.

RESULTS

During the 6-year period, seven EBP were performed in children aged 12 years or younger. Four out of the seven children had undergone a diagnostic spinal puncture, two had spinal anaesthesia and one child had spinal puncture for treatment of postoperative hygroma. Five children had a typical PDPH, one child had a cerebrospinal fluid fistula headache and one child had a headache similar to his migraine. EBP was performed 2-19 days after spinal puncture with 0.3 ml.kg-1 (mean) of autologous blood injected into the epidural space.

CONCLUSIONS

EBP gave some relief of symptoms in all children. No complications related to EBP were noticed.

Randomized, double-blind, crossover, placebo-controlled trial of intravenous ondansetron for the prevention of intrathecal chemotherapy-induced vomiting in children

BACKGROUND

The purpose of this study was to determine the effectiveness of intravenous ondansetron in preventing vomiting after the administration of intrathecal chemotherapy in children.

PATIENTS AND METHODS

Twenty-six children (ages 18 mo to 15 y) receiving intrathecal chemotherapy with either methotrexate or the combination of methotrexate, hydrocortisone, and Ara-C for the prophylactic treatment of central nervous system leukemia were randomly assigned to receive an infusion of normal saline or ondansetron at one of two doses (0.15 or 0.45 mg/kg) 30 minutes before undergoing the procedure. One hundred forty-six infusions were administered (51 placebo, 47 at the lower ondansetron dose, and 48 at the higher dose). Each patient acted as his or her own control, and each patient was studied at least three times.

RESULTS

Twenty-three of 26 patients (88.5%) had postprocedural vomiting on at least one occasion. At least one episode of vomiting occurred during the 24 hours after the procedure in fifty-two of the procedures (35.6%). The incidence of vomiting was significantly greater after infusion of placebo than after either low-dose or high-dose ondansetron. The likelihood of severe vomiting was even more significantly reduced by the preadministration of ondansetron. Almost all of the intrathecal treatments associated with severe vomiting occurred after the infusion of placebo.

CONCLUSIONS

Vomiting induced by intrathecal chemotherapy can be greatly reduced by the intravenous administration of ondansetron before the procedure, and severe vomiting can be virtually eliminated.

Post-dural puncture headache and other complications after lumbar puncture

In pediatric hematology and oncology specialties, lumbar punctures are frequently performed for diagnostic and therapeutic purposes. Lumbar puncture is a procedure that is generally well tolerated with minimal adverse effects. However, adverse effects do occur. Post-dural puncture headache (PDPH) is the most common adverse effect after lumbar puncture. A better understanding of the pathophysiology of PDPH and attention to needle selection and technique may lessen the occurrence of PDPH. A review of the literature that addresses the variables associated with PDPH and its prevention are presented. Other adverse effects after lumbar puncture include dysesthesias, backache, transient radicular irritation, nerve palsies, infectious processes, herniation, and bleeding disorders. Although most adverse effects are mild and resolve without intervention, others require astute diagnosis and management. This review discusses the general principles in the clinical presentation of adverse effects after lumbar puncture and offers interventions for management. The prevention and the recognition and treatment of adverse effects is the role of the entire health care team that cares for children who require lumbar puncture. As such, implications for the role of nursing are essential before, during, and after a lumbar puncture and are briefly discussed.

Caudal epidural blood patch for treating intractable vomiting in a child after placement of a permanent intrathecal catheter

Postdural puncture cerebral spinal fluid (CSF) leak most often manifests as a postdural puncture headache (PDPH). The reported frequency in young children varies (1-4). Persistent CSF leak may also be present without PDPH. We present a case of postoperative nausea and vomiting resulting from a presumed lumbar CSF leak in a nonverbal child after surgical placement of a permanent intrathecal catheter. Treatment with an epidural blood patch (EBP) via the caudal approach resulted in complete relief of symptoms.

Acute neurologic complications in children with systemic cancer

Neurologic complications are common in children with cancer, but the literature dealing with this subject is sparse. Using a symptoms and signs approach, the most common causes for requesting a neurologic evaluation for this population are reviewed. The spectrum of neurologic symptoms in children with cancer differs from adults and requires the consulting neurologist to have a thorough knowledge of childhood cancer and its effects on the nervous system.

Needle design does not affect the success rate of spinal anaesthesia or the incidence of postpuncture complications in children

BACKGROUND

In adults, pencil-point spinal needles are believed to be less traumatic and therefore to be superior compared to cutting-point needles with respect to success rate and postpuncture complications. The aim of this randomised, parallel groups and prospective study was to record the success rate and to evaluate the incidence of complications following spinal anaesthesia with the two types of needles in children.

METHODS

We studied 215 children aged 1 to 18 years. A 25-gauge needle was used in children up to 7 years (n=96) and a 27-gauge needle in older children (n=119). During lumbar puncture with either a cutting-point (n=109) or a pencil-point (n=106) spinal needle, we recorded puncture characteristics and the success of cerebrospinal fluid (CSF) aspiration. Hyperbaric bupivacaine 5 mg ml(-1) at a dose of 0.3-0.4 mg kg(-1) was used for the spinal anaesthesia. The incidence of postdural puncture complications was recorded from diaries completed by the children and parents one week after the lumbar puncture.

RESULTS

The success rate of the spinal anaesthesia was 97% without difference between the needles. The success rate was higher when the aspiration of CSF was easy compared to if it was difficult (98% vs. 88%, P=0.02). Two hundred and seven diaries were returned (97%). Twenty-four children developed a headache, 8 of which were classified as a postdural puncture headache (PDPH), 6 with the cutting-point needle and 2 with the pencil-point needle (n.s.). Nine children developed signs of transient radicular irritation with no difference between the needles.

CONCLUSION

Both types of spinal needles can be used in children, and a free aspiration of CSF results in a high success rate of the spinal block. Postpuncture complications are as common in children as in adults.