Wednesday, 6 June 2018

Atraumatic LP needles: what you need to know

This week's BMJ has a rapid recommendation piece on the advantages of using atraumatic needles in routine clinical practice. Let's hope this will now drive the necessary changes we have been arguing for, for several years. Our aim is to get neurologists and MSers to rethink CSF analysis for monitoring MS.



What you need to know:
  1. Post-dural-puncture headache is a common complication after lumbar puncture, affecting up to 35% of patients
  2. This headache results from sustained leakage of cerebrospinal fluid from a dural tear; it can be debilitating and require return to hospital for narcotics or invasive therapy
  3. We issue a strong recommendation for use of atraumatic needles in all patients (adults and children) undergoing lumbar puncture because they decrease complications and are no less likely to work than conventional needles
  4. Atraumatic needles are more expensive, but evidence suggests that they reduce costs overall compared with conventional needles

Why is this paper so important? 

We have known about post-LP headaches being much more common with traumatic or cutting LP needles, but despite this many NHS hospitals continue to purchase these needles because they are cheaper. The people in charge of procurement have to stay in budget this year and hence don't really care about the downstream costs of treating the complications of LPs nor the misery caused to thousands of patients every year suffering from the complications of LPs. We started our #AtraumaticNeedle campaign several years ago as part of our public engagement programme in the run-up to our PROXIMUS trial.  The following are our three papers on the subject and our #ClinicSpeak LP Web App

What have your LP experiences being like; good, bad or indifferent? 

Barts-MS paper 1

Davis et al. Atraumatic needles for lumbar puncture: why haven't neurologists changed? Pract Neurol. 2016 Feb;16(1):18-22.

Diagnostic lumbar puncture is a key procedure in neurology; however, it is commonly complicated by post-lumbar puncture headache. Atraumatic needle systems can dramatically reduce the incidence of this iatrogenic complication. However, only a minority of neurologists use such needles. In this paper, we discuss possible reasons why neurologists have not switched to new technology, looking more at diffusion of innovation rather than lack of evidence. We suggest ways to overcome this failure to adopt change, ranging from local interventions to patient empowerment.

Barts-MS paper 2

Davis et al. Change practice now! Using atraumatic needles to prevent post-lumbar puncture headache. Eur J Neurol. 2014 Feb;21(2):305-11.

BACKGROUND AND PURPOSE: Lumbar puncture (LP) is a key diagnostic procedure in medicine. Post-lumbar puncture headache (PLPHA) is a well-recognized complication of LP. Evidence suggests that using atraumatic needles for diagnostic LP (ATNLP) reduces the risk of PLPHA. However, clinicians in Europe and the USA routinely use traumatic needles for diagnostic LP (TNLP). The occurrence of PLPHA following ATNLP and TNLP was compared in a clinical setting. Further, a survey was performed exploring use of ATNLP amongst UK neurologists.


METHODS: Service development study. Patients were followed up 2 and 7 days after LP using blinded telephone assessment. A questionnaire was developed to assess the use of ATNLP amongst UK neurologists. Frequency, onset, duration and severity of PLPHA were recorded as were use of analgesia, general practitioner consultations, hospital readmissions, days off work due to PLPHA and cost. Neurologists were asked about their familiarity with, and use of, ATNLP.

RESULTS: One hundred and nine participants attending the Royal London Hospital were included, and 74 attendees of the Association of British Neurologists 2012 conference completed an on-site questionnaire. ATNLP reduced the rate of PLPHA (27.1% vs. 60.4%; P < 0.01). In those participants who developed PLPHA symptoms were short-lived (mean 50 h vs. 94 h, P = 0.02) and less severe after ATNLP. Use of ATNLP led to significant cost savings. Only one in five UK neurologists regularly use ATNLP stating lack of training and availability of atraumatic needles as main reasons.

CONCLUSIONS: ATNLP significantly reduces the risk of PLPHA. Training is required 3 to facilitate a change from TNLP to ATNLP amongst clinicians.

Barts-MS paper 3

Gafson et al. Towards the incorporation of lumbar puncture into clinical trials for multiple sclerosis. Mult Scler. 2012 Oct;18(10):1509-11.

ProfG    

11 comments:

  1. Every stab hit bone, I had flashbacks for a couple of years but I had recently had a nasty relapse so was very unwell. My body overreacts to stress at the best of times.

    ReplyDelete
  2. I hope the message gets through. To leave people who are already going through a probable relapse and the stress of not knowing what's wrong with them with a splitting headache isn't kind if an alternative is available.

    If it helps anyone to know, I've had an LP with atraumatic needle and had no headache at all :)

    I also had a really long LP as it took ages to get the needle in the right place. Amazingly it hurt very little as I was well topped up with LA :)

    ReplyDelete
  3. Solid but overdue work for which Barts MS team is way ahead of the field.
    I've now had two LPs, the first with a conventional needle, the second with an atraumatic needle and have very strong views about this issue.

    Conventional needle: Painful procedure with practitioner poking around until eventually started to extract the fluid. Took ages to get enough, with the procedure stopping when I could feel the needle... When finally allowed to stand up, immediate headache the likes of which I've not experienced before, only abating when I lay down. This continued for 10 days solid before it finally passed, during which time I could do nothing. Looking back I consider I lost 10 days of my life through this and what's worse for any MS patient, my mobility plummeted as a result of the inactivity, contributed significantly to EDSS increase.

    I said I'd never do a LP again but turns out I needed to at another hospital, so off I went full of trepidation.

    Atraumatic needle: A few minutes into the procedure I was wondering what the practitioner was doing - they seemed to be occupied with things other than me. Oh! It was all over - they had enough fluid and were in the process of sealing the vials. After lying down for the required time I then stood up expecting the worst - but nothing happened. I waited expecting it to be delayed onset - still nothing. Wow! Pleasantly surprised and feeling no difference to when I went in. There was no problem at all in the following days.

    Conclusion: Conventional needles are barbaric and should banned for LP's - this is not just a slight headache its off the scale bad.

    ReplyDelete
    Replies
    1. Exactly the same. When I phoned the hospital about the headache and nausea I had, they told me to take paracetamol and see my GP!

      Delete
  4. Or just get an anaesthetist to do the LP ... we've been using and advocating atraumatic needles for years ...

    ReplyDelete
  5. Surely this is a no-brainer for neurologists. Can I suggest you make a downloadable LP card for people with MS to take their neurologist when having an LP.

    ReplyDelete
    Replies
    1. Just send them here: http://www.clinicspeak.com/lumbar-puncture/

      Delete
  6. Both my LPs were great using atraumatic needles. One was even done by a 1st year resident!

    ReplyDelete
  7. Check, check, check.

    I had my LP in the. mid-90s followed by the more or less predictable iatrogenic headache and would not willingly submit to that again.

    I can see how the progress of research is. impeded by people choosing not to have their CSF assayed and therefore strongly favour atraumatic needles.

    Australia EDSS 8.5 9HPT 120, 420

    ReplyDelete
  8. After reading all this, I'm so glad the neurologists never prescribed an LP!

    But the atraumatic needle sounds ok

    ReplyDelete

Please note that all comments are moderated and any personal or marketing-related submissions will not be shown.