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When the Easy LP Isn't Easy
Lumbar punctures can be mercurial procedures. There are certainly patients in whom it can be predicted that a lumbar puncture will be challenging. Obesity, patients with known degenerative changes, and agitated patients all present unique challenges when it comes to successfully completing a lumbar puncture. There are patients, however, who throw you a bit of a curveball. Sometimes cooperative patients with good landmarks, in whom you had every expectation that you would find success, become seemingly impossible to successfully complete a lumbar puncture.
For the provider, knowing how to troubleshoot the unexpectedly difficult lumbar puncture can be the difference between success and failure.
Airways, like Martinis, are Best "Dry"
Have you ever looked down the blade of a laryngoscope and said to yourself, “Damn! This airway is just too dry!” I thought not. Rather, we often look down the blade into a mucky swamp of secretions that drip from the pharyngeal walls like drool from a big, sloppy dog, and often obscure familiar landmarks and goop-up our optical and video adjuncts. Is there no solution? There is! Let us review an illustrative case...
Thoracentesis
General Considerations
Both the diagnostic and therapeutic thoracenteses are performed using a similar technique. The major difference is the amount of fluid removed. The proceduralist may also choose to only use the needle technique as opposed to the needle-catheter unit when obtaining fluid for diagnostic purposes only.
It is generally recommended that needle size be limited to 18-gauge or smaller to minimize risk of pneumothorax and damage to nearby structures.
US-guided thoracentesis is associated with a significantly lower rate of complications and has become the standard of care. (1) Real-time ultrasound (US) guidance is recommended for small or loculated effusions when there is concern that the diaphragm or lung tissue is <10mm from the pleural surface. It is also recommended in patients with relative contraindications such as coagulopathies and the mechanically ventilated patient.