Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine
1) When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult-to-palpate landmarks.
2) We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients.
3) We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site.
4) We recommend that a low-frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high-frequency linear array transducer may be used in nonobese patients.
5) We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces.
6) We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site.
7) We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used.
8) We recommend that novices should undergo simulation-based training, where available, before attempting ultrasound-guided lumbar puncture on actual patients.
9) We recommend that training in ultrasound-guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary.
10) We recommend that novice providers should be supervised when performing ultrasound-guided lumbar puncture before performing the procedure independently on patients.
© 2019 Society of Hospital Medicine
METHODS
Detailed methods are described in Appendix 1. The SHM Point-of-care Ultrasound (POCUS) Task Force was assembled to carry out this guideline development project under the direction of the SHM Board of Directors, Director of Education, and Education Committee. All expert panel members were physicians or advanced practice providers with expertise in POCUS. Expert panel members were divided into working group members, external peer reviewers, and a methodologist. All Task Force members were required to disclose any potential conflicts of interests (Appendix 2). The literature search was conducted in two independent phases. The first phase included literature searches conducted by the six working group members themselves. Key clinical questions and draft recommendations were then prepared. A systematic literature search was conducted by a medical librarian based on the findings of the initial literature search and draft recommendations. The Medline, Embase, CINAHL, and Cochrane medical databases were searched from 1975 to December 2015 initially. Google Scholar was also searched without limiters. Updated searches were conducted in November 2016, January 2018, and October 2018. The search strings are included in Appendix 3. All article abstracts were first screened for relevance by at least two members of the working group. Full-text versions of screened articles were reviewed, and articles on the use of ultrasound to guide LP were selected. In addition, the following article types were excluded: non-English language, nonhuman, age <18 years, meeting abstracts, meeting posters, narrative reviews, case reports, letters, and editorials. Moreover, studies focusing on the use of ultrasound guidance for spinal nerve root injections, regional anesthesia, and assessment of lumbar spine anatomy alone were excluded. All relevant systematic reviews, meta-analyses, randomized controlled trials, and observational studies of ultrasound-guided LP were screened and selected. Final article selection was based on working group consensus, and the selected literature was incorporated into the draft recommendations.
The Research and Development (RAND) Appropriateness Method that required panel judgment and consensus was used.21 The 27 voting members of the SHM POCUS Task Force reviewed and voted on the draft recommendations considering the following five transforming factors: (1) Problem priority and importance, (2) Level of quality of evidence, (3) Benefit/harm balance, (4) Benefit/burden balance, and (5) Certainty/concerns about PEAF (Preferences/Equity/Acceptability/Feasibility). Panel members participated in two rounds of electronic voting using an internet-based electronic data collection tool (REDCap™) in February 2018 and April 2018 (Appendix 4). Voting on appropriateness was conducted using a 9-point Likert scale. The three zones of the 9-point Likert scale were inappropriate (1-3 points), uncertain (4-6 points), and appropriate (7-9 points). The degree of consensus was assessed using the RAND algorithm (Appendix Figure 1 and Table 1). Establishing a recommendation required at least 70% agreement that a recommendation was “appropriate.” A strong recommendation required 80% of the votes within one integer of the median, following the RAND rules. Disagreement was defined as >30% of panelists voting outside of the zone of the median.
Recommendations were classified as strong or weak/conditional based on preset rules defining the panel’s level of consensus, which determined the wording of each recommendation (Table 2). The revised consensus-based recommendations underwent internal and external reviews by POCUS experts from different subspecialties. The final review of this position statement was performed by members of the SHM POCUS Task Force, SHM Education Committee, and SHM Executive Committee. The SHM Executive Committee endorsed this position statement in June 2018 before submission to the Journal of Hospital Medicine.
