Textbook+of+Critical+Care+(6th)_2011_部分6

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1、W18 W18LumbarPuncturePATRICKM.KOCHANEKBeforeProcedurethistechnique.Incasesofdifficultlumbarpunctureinobesepatients,bedsideultrasoundcanbehelpful.INDICATIONS•Suspicionofcentralnervoussystem(CNS)infectionProcedure•Suspicionofsubarachnoidhemorrhage•Theneedtoobtaincerebrospinalfluidtodiag

2、noseotherinflam-•PlacethepatientinthelateraldecubituspositionwithkneesflexedmatoryordegenerativeCNSdiseasestotheabdomenandheadflexedwiththechintowardthechest.•Reductionofcerebrospinalfluid(CSF)pressureinpseudotumor•Positionthepatient’sbackascloseaspossibletotheedgeofthecerebribedneare

3、sttheexaminer.•Beforepreparingtheskin,locatetheL4-L5andL5-S1interspacesandmarkthem.CONTRAINDICATIONS•Theskinshouldthenbepreparedwithchlorhexidineorpovi-•Absolute:done-iodine.Thepreparationshouldproceedoutwardinaspiral•Intracranialorspinous(especiallyintramedullary)mass(e.g.,andcoverse

4、veralinterspacesincasemultipleattemptsaretumor,abscess).Ifthereisconcern,animagingstudyshouldbenecessary.performedbeforetheprocedure.Arapiddecreaseinintracranial•Drapethepatient’sbackwithasterilesheetwithanopeningforpressurefromwithdrawalofCSFcouldprecipitateherniationthepreparedareas

5、othatitcoverstheposterioriliaccrest.orworseningofspinalcordfunctionifamasslesionispresent.•Anesthetizetheskinwith1%lidocaineusinga25-gaugeneedle,•Overlyingskininfectionwhichmaybeexchangedforalonger22-gaugeneedletoreach•Lumbarspinediseasedeepertissues.•Relative:•Usinga20-or22-gaugespin

6、alneedle,advanceitwiththestylet•Coagulopathyand/orthrombocytopenia,becauseanepiduralinplacetoavoidintroductionofepidermalcellsintothesub-hematomacandevelopatthepuncturesite.Freshfrozenplasmaarachnoidspace.andplateletsshouldbeinfusedtocorrecthematologicabnor-•Directthebeveloftheneedleu

7、pwardtoseparatethefibersofthemalitiesbeforetheprocedure.Ifacoagulopathyisdiscoveredligamentumflavum.Angletheneedle15degreescephaladandaftertheprocedure,therapyshouldstillbegiven,becausebleed-slightlydownwardtowardthebed.ingcanoccurformanyhours.•Whentheduraispuncturedandaslight“pop”isf

8、elt,t