Evidence-Based Practice Recommendations to Prevent/Manage Post-Lumbar Puncture Headaches in Pediatric Patients Receiving Intrathecal Chemotherapy

Abstract

Post lumbar puncture headaches (PLPH) are a known complication of lumbar puncture procedures. Children undergoing treatment for cancer often undergo multiple lumbar punctures placing them at increased risk for PLPHs. There are currently no guidelines for the prevention or management of PLPH in children. A team was therefore assembled to conduct a systematic review of the evidence in relationship to PLPHs in the pediatric population. Clinical questions were developed and used to guide the literature review. Twenty four articles were deemed appropriate for use and were evaluated utilizing the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. Based on the review of evidence, strong recommendations are made for the use of smaller needle sizes and for the use of pencil point needles during lumbar puncture procedures. Weak recommendations are made for needle orientation and positioning following the procedure as well as for interventions utilized to treat PLPH once they occur. There is a need for additional, pediatric-specific, studies to further examine the issue of PLPH prevention and treatment.

Epidural blood patch for post-dural puncture headaches in adult and paediatric patients with malignancies: a review

“…To date, no adverse events have been reported. 11,30 Utilisation of an epidural blood patch in the oncology population should be considered if conservative management fails, and after extensively evaluating patient-specific risks and benefits together with the anaesthetist, patient (or family), and oncologist.…”

“…Reducing LP needle size, utilisation of a pencil-point needle, using a steeper angle of insertion, orienting the bevel parallel with the longitudinal neuraxis (if using a cutting needle), and reinserting the stylet before needle withdrawal can reduce PDPH incidence. 11 Epidural saline injection at the time of LP has been demonstrated to reduce the rate and severity of PDPH in 33 young adult patients with acute lymphoblastic leukaemia (ALL). 12 Lastly, procedural experience plays a significant role in the incidence of PDPH, as inexperienced providers may cause multiple unrecognised dural punctures.…”

“…5 Although 85% of PDPH in adult patients resolves within 6 weeks with conservative management, this approach is less effective in decreasing the PDPH duration in paediatric patients. 5,11 Conservative management of PDPH involves supine positioning, increased fluid intake, caffeine administration, and oral analgesics (such as NSAIDs and acetaminophen). When conservative treatment fails or PDPH is debilitating, more-aggressive management with an epidural blood patch (EBP) may be offered.…”

Reflections on the Past Decade in Evidence-Based Practice Within the Children's Oncology Group

“…Rodgers, Withycombe, and Hockenberry (Rodgers et al, 2014). Selected EBP projects from COG (Rusch et al, 2014) and Duke University (Mize et al, 2014) were subsequently featured in a COG-led preconference workshop -"The Process of Evidence-Based Practice"-held at the APHON Annual Conference in September 2015.…”

Children's Oncology Group 2023 blueprint: Nursing discipline

“…A wide variety of nursing care issues has been addressed by the COG nursing EBP process to date 7,12–27 (Table 2). Additionally, the discipline's EBP projects have been widely disseminated to pediatric oncology nurses through presentations at COG meetings, and through the COG educational track sessions at annual APHON meetings.…”