Lumbar Puncture Procedure Note (Neonate)

Procedure: Lumbar Puncture

Date/Time: [Date; start time - end time]

Location: [NICU / ED / inpatient ward / other]

Chronologic Age: [days]

Gestational Age at Birth / Corrected GA: [weeks; if applicable]

Weight: [kg]

Operator: [name and role]

Assistant(s): [name(s) and role(s) / none]

Indication

[Brief indication for lumbar puncture, 1–2 sentences stating clinical question prompting LP]

Pre-Procedure Assessment

• Respiratory support: [current device and settings] (State "unknown at time of procedure" if unavailable.)
• Hemodynamic status: [stable / unstable; pertinent vitals; vasoactive support if any]
• Bleeding risk: [recent platelet count with date/time; anticoagulant status; coagulation parameters if available] (State "unknown at time of procedure" if unavailable.)
• Skin/anatomic considerations: [normal / describe abnormality] (Include only if abnormal.)

Consent

Consent obtained from [name and relationship] on [date/time] as [verbal / written]. Indication, benefits, risks, and alternatives discussed; questions answered.

(If emergent and consent not obtained, document emergency exception circumstances and plan to update family.)

Time-Out

Time-out performed with bedside team confirming correct patient, procedure, site/positioning, allergies reviewed, and equipment available. (If time-out could not be performed, document why and what alternative verification occurred.)

Analgesia and Sedation

• Nonpharmacologic comfort: [swaddling / facilitated tuck / non-nutritive sucking / oral sucrose or glucose; timing relative to procedure]
• Topical anesthetic: [agent and application time / not used]
• Local anesthesia: [agent, concentration, dose/volume, route / none]
• Systemic analgesia/sedation: [medication(s), dose, route, time; monitoring approach / none] (If separate sedation record exists, reference it and summarize medications and tolerance.)

Positioning and Technique

• Position: [lateral decubitus / seated]; flexion: [degree]; positioning assistance by: [name/role]
• Interspace targeted: [L3–4 / L4–5 / other]
• Ultrasound: [used for landmarking / used for guidance / not used]
• Sterile technique: [skin antiseptic agent / standard sterile prep per unit protocol]; sterile drape applied; operator PPE donned
• Needle: [gauge, length, type]

Procedure Details

• Total attempts: [#]
• Attempt details: [For each attempt: interspace level, outcome (dry tap / traumatic / successful), reason if unsuccessful]
• Opening pressure: [value in cm H₂O with method / not obtained]
• CSF appearance: [clear/colorless / blood-tinged / grossly bloody / xanthochromic / cloudy/turbid]; cleared by subsequent tubes: [yes / no / N/A]
• CSF volume: [total mL, measured/estimated]; Tube distribution: [# tubes, ~volume per tube]
• Paired serum glucose: [time and value / not obtained]

(If no CSF obtained, state "No CSF obtained" and document follow-up plan.)

Studies Sent

[Cell count with differential, protein, glucose, Gram stain, bacterial culture] (List additional tests if ordered: HSV PCR, enterovirus PCR, meningitis/encephalitis panel, fungal/AFB studies, other.) Specimens labeled at bedside and sent to laboratory.

(If no CSF obtained, state "No studies sent" and document follow-up plan.)

Outcome and Complications

Procedure outcome: [successful / unsuccessful / aborted]

Patient tolerance: [tolerated well / brief description of distress or instability]

Complications: [none / list specific events: desaturation, apnea, bradycardia, bleeding, traumatic tap, other] (If complications occurred, document interventions performed.)

Post-Procedure Plan

• Site care: [dressing applied; bleeding or CSF leak: none / describe]
• Monitoring: [respiratory monitoring; vital sign frequency; pain reassessment]
• Escalation criteria: [notify provider for apnea, bradycardia, desaturation, neurologic change, persistent bleeding/leak]
• Diagnostic follow-up: [brief plan]

Estimated Blood Loss: [minimal / none]

Condition at End of Procedure: [stable / unstable; brief qualifiers]