Sunday, April 23, 2006

Taps

We recently had a baby in our NICU that had four spinal taps in 10 days. That's a lot. If the first tap had been successful there would have only been the need for one or two taps.

The baby's mother had syphilis shortly before she delivered. The baby needed treatment with antibiotics for at least 10 days to ensure she didn't get syphilis, but we needed to be sure the baby didn't have syphilis in the brain, so my partner, appropriately, did a spinal tap. Unfortunately, he only got a small amount of fluid out, enough to tell us that there were a few too many infection fighting white blood cells in the spinal fluid - which suggests possible brain infection - but not enough for a culture to show us what germ might be infecting the brain. My partner tried another spinal tap the next day. It was unsuccessful. Another partner then did a spinal tap the following day; she obtained enough fluid, but the fluid had blood in it and interpretation of the results was difficult.

We discussed the case with our infectious disease specialists and agreed to stop doing spinal taps and just treat the baby for awhile. Near the end of the antibiotic treatment, I was "on service" - doing the daily rounds in the NICU - and again consulted the infectious disease folks. They suggested a fourth spinal tap, to make certain there were no signs of meningitis. I groaned whenI heard that but did it anyway. Fortunately, this time we had a clean, bountiful tap and the fluid showed no signs of infection.

I suspect that many of the non- physician readers of this blog are perhaps concerned or annoyed by this plethora of spinal taps. Trust me , we weren't very happy about it either. It's one of those situations in medicine, though, where in spite of everyone's best efforts, unfortunate things happen. My partners who did the initial spinal taps are very good at doing them; in fact, they're the procedure king and queen of our NICU. But the taps just didn't go well in this baby. I would have hated it if this happened to my own baby, but even though this much trouble with spinal taps is unusual, I don't know how to guarantee it won't happen again. It's an imperfect world - a lousy, but true, excuse.

12 Comments:

Blogger Flea said...

In a perfect world, mom wouldn't have had syphilis...

Flea

5:05 PM  
Blogger Judy said...

Sometimes it's just how things play out, but the person positioning the baby plays a big part in the success of the procedure too. I wouldn't be happy if that was my baby, but some things just aren't optional.

5:07 PM  
Anonymous Lisa said...

OK. As the mother of two preemies in neo-nate wards this entry scares the hell out of me. One of my preemies is in medical school. The other is fighting in Baghdad. But I had a friend recently who had a spinal tap to test for MS. She experienced a leak and was in hell for a week. How do you know this baby wasn't simularly affected?

9:29 PM  
Blogger Ex Utero said...

I agree with Judy. I think it's as much about how good the nurse is at holding the infant (or the physician insuring that the nurse is holding the infant in the right position). If you can get that infant bent into a perfect "U" and the spine exactly straight in alignment for just long enough to get the needle in, it improves the odds.
I do a lot less of these than I used to. I know we have to do them, especially in the ER, but I think we were probably over doing it in the 1990s.

9:38 PM  
Blogger Tara's World said...

In todays world how in the heck can you get syhillis, or let it get to that point? Spinal taps are important and the baby will never remember them. My daughter had 3 by the time she was 2 to try and figure out why she kept running really high fevers that came out of nowhere.

9:54 AM  
Blogger neonataldoc said...

Thanks, all. I agree, holding the baby is about as important as the actual tapping. Lisa, the baby did not seem to be in any pain between taps. I doubt she had a spinal headache, but we cannot be sure. Tara, this woman got syphilis the same way people have been getting it for centuries. She didn't have symptoms; it was picked up by a routine screening lab done during pregnancy. Interestingly, she was a Muslim woman from a developing country, not the normal population in which we see syphilis. As one of our nurses said, though, men all over the world mess around.

10:14 PM  
Anonymous Kim said...

Better to know than to hope everything is okay.

The only time you get a tap in ER is if you are under 8 weeks old and running a fever.

I hold 'em. You would think that being in the fetal position for 40 weeks would make these babies easy to position.

Not. Somehow it isn't that easy to fold 'em back!

11:15 AM  
Blogger Clark Bartram said...

I don't think that infants get spinal headaches. They make the stuff fast enough I guess. I have yet to do a tap, I'm approaching 50 now(small potatoes to many of you but still a good number), where the baby didn't go to sleep as soon as I hit fluid. The only times I've had a baby be irritable afterwards is when they actually had meningitis which is probably a more likely cause for discomfort at that point than the tap.

I think that LPs get a bad rap. As a parent I can understand being freaked out but as a pediatrician I know how safe the procedure is. I personally think they are less traumatic than an IV placement. I fully agree that 99% of a good tap is because of a good hold. There is a nurse on the floor here that I will hunt down to hold for me because she does is perfectly.

12:26 AM  
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