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Original Investigation |

Intravenous Fluid Bolus Prior to Neonatal and Infant Lumbar Puncture A Sonographic Assessment of the Subarachnoid Space After Intravenous Fluid Administration Online Only

Jessica Rankin, MD1,3; Vincent J. Wang, MD, MHA1,3; Fariba Goodarzian, MD2,3; Hollie A. Lai, MD2,3
[+] Author Affiliations
1Department of Emergency and Transport Medicine, Children’s Hospital Los Angeles, Los Angeles, California
2Department of Radiology, Children’s Hospital Los Angeles, Los Angeles, California
3Keck School of Medicine, University of Southern California, Los Angeles
JAMA Pediatr. 2016;170(3):e154636. doi:10.1001/jamapediatrics.2015.4636.
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Importance  Neonatal and infant lumbar puncture is a commonly performed procedure in emergency departments, yet traumatic and unsuccessful lumbar punctures occur 30% to 50% of the time. Dehydration may be a risk factor for unsuccessful lumbar punctures, but to our knowledge, no studies have investigated the use of intravenous (IV) fluid bolus prior to lumbar puncture.

Objective  To investigate the association of IV fluid bolus administration with the sonographic measure of the neonatal and infant lumbar subarachnoid space. We hypothesized that IV fluids would increase subarachnoid space size.

Design, Setting, and Participants  Prospective observational study conducted from August 2012 to April 2015.The study took place at the emegency department of the Children’s Hospital Los Angeles, an urban pediatric emergency department with an annual census of 76 000 visits.A convenience sample of patients aged 0 to 3 months were enrolled if they had a clinical presentation consistent with pyloric stenosis. This population was used as a proxy because they are similar in age to patients undergoing lumbar puncture for evaluation of neonatal fever and are routinely given IV fluids for dehydration.

Exposures  Patients with a sonographic diagnosis of pyloric stenosis underwent additional ultrasonography evaluation to determine the size of the subarachnoid space before and after IV fluids.

Main Outcomes and Measures  Primary outcomes included the difference in the size of the subarachnoid space in millimeters squared before and 1 hour after administration of an IV fluid bolus in the emergency department. Interobserver consistency for the subarachnoid space measurement between attending radiologists was measured using intraclass correlation coefficient. The Wilcoxon signed-rank test was used to examine changes in subarachnoid space measurements (millimeters squared).

Results  The study sample consisted of 40 patients with a mean (SD) age of 37 (11.3) days (range, 15-71 days). The mean (SD) size of the subarachnoid space before and 1 hour after IV fluid bolus was 37.8 (11.1) mm2 and 36.9 (11.2) mm2 respectively (P = .42). The intraclass correlation coefficient ranged from 0.96 to 0.99 (95% CI, 0.90-0.99).

Conclusions and Relevance  Intravenous fluid boluses were not associated with a significant increase in the sonographic measure of the neonatal and infant subarachnoid space.

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Figure 1.
Patient Enrollment Diagram and Study Protocol

Patients were weighed, given a study physical examination, and administered intravenous (IV) fluid bolus following the first ultrasonography. Patients were weighed and given a study physical examination following the second ultrasonography.

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Figure 2.
Transverse View of Lumbar Spine at the Conus Medullaris Before and After intravenous (IV) Fluid Administration
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