Procedurer What determines a lumbar puncture is rarely the needle itself. It is the decision whether to perform it now or after imaging, how the…

…is decided before the needle goes in: the choice of site, the use of ultrasound throughout the puncture, and maintaining maximal barrier precautions without shortcuts…

…Otherwise: Type Contraindication : : Absolute No safe pocket of fluid to puncture (no ultrasound verified fluid) Relative Uncorrected coagulopathy or thrombocytopenia Relative Ongoing anticoagulant treatment — plan…

…that clots before the smears are made is unusable, no matter how well the puncture went. Indications Unexplained cytopenia in one or more cell lines…

…osteoarthritis related joint disease. Contraindications Infection of the skin or soft tissues over the puncture site — use another approach or refrain. Bacteraemia without suspicion of…

…straightforward: ultrasound to find the fluid, an insertion site in the left lower quadrant lateral to the rectus sheath, and a cell count plus albumin…

…analysers — check locally. Contraindications Peripheral venous cannula: Infection, burns or trauma at the puncture site. An arm with an arteriovenous fistula, previous axillary clearance or…

…are as a rule left open. Facial bites can be sutured after careful debridement because of the cosmesis, often with antibiotic prophylaxis. Deep puncture wounds …

…a smaller size in children. A set with an integrated guidewire (Seldinger technique) helps when the vessel is difficult to puncture. Sterile preparation with chlorhexidine…

…liver, lung or vessel lies in the path of the needle. Access Puncture site Direction Comment : : : : Subxiphoid 1–2 cm below and to the left