P3.S366: Ultrasound Assisted Lumbar Punctures in Children < 6 Months

Purpose/Objectives: Lumbar punctures (LP) are critical in the work-up of infants with fever to evaluate for meningitis. National data suggests that many clinicians struggle to perform this procedure successfully. Inability to obtain this data leads to additional procedures, delayed treatment, and unnecessary hospitalization/antimicrobials. Traumatic LPs (>10,000 red blood cells/µL) negate the cell count as a reliable surrogate for infection in those cases where antibiotics are administered prior to CSF being obtained. Point-of-care ultrasound (POCUS) assistance has been associated with improved success in obtaining LPs, though is not routinely utilized by clinicians for this procedure. Our goal is to obtain cerebral spinal fluid (CSF) for >95% of infants within 3 attempts and to obtain CSF before antibiotics are administered in >75% of cases.

Design/Methods: Utilizing our institution’s electronic medical record (EMR), we reviewed all infants < 6 months admitted to the pediatric ward who had an LP attempted to evaluate for meningitis from January 2021 through June 2023. Based on our facility’s laboratory processing, we assume all CSF marked “collected” within 30 minutes of antibiotic administration occurred before antibiotics were delivered. Following extensive research, practice, and collaboration, we have implemented an LP POCUS training curriculum for residents in Pediatrics, Emergency Medicine, and Family Medicine. A post-procedural survey is being used to track procedure feedback moving forward in addition to quarterly reviews of our performance.

Results: Pre-implementation: CSF was ultimately obtained in 33/35 infants (94%) where an LP was attempted. CSF was obtained within 3 attempts for 27/35 infants (77%). The average number of recorded LP attempts in an infant was 3, interquartile range (IQR) 1-3, and max 10. 14/35 infants (40%) received antibiotics before a CSF sample was obtained. The average time from antibiotics to obtaining an LP was 8.8 hours, IQR 1.4-6.2 hours. There were 16 infants (46%) who had either a traumatic LP or no CSF for analysis, including 7 (20%) where LP occurred following the administration of antibiotics.

Post-implementation: Since our project commenced in December 2023 there have been 3 infants < 6 months admitted to the pediatric ward with concern for meningitis. CSF was obtained in all 3 prior to antibiotics and within 3 attempts (Table 1). Our post-procedural survey captured 7 total procedures including infants who were evaluated in the nursery, neonatal ICU, and emergency room. Overall, 6/7 procedures were successful and 5/7 required 3 or less attempts (Table 2).

Conclusion/Discussion: Our pre-implementation review is congruent with national data, demonstrating that many clinicians struggle to perform an LP successfully. One limitation of our chart review is that LP attempts are not consistently charted and so this baseline-average is likely underestimated. While we have limited post-implementation data, our results show promise towards increasing success, reducing attempts, and decreasing time to antibiotics.