Lumbar Puncture with Intrathecal Chemotherapy Procedure Note

Date/Time: [Start time — End time]

Location: [Bedside / Clinic / Procedure suite / IR suite]

Operator: [Name, role, service]

Patient Position: [Lateral decubitus (left / right) / Sitting]

Indication

[Primary indication for lumbar puncture with intrathecal therapy in one to three sentences. Note whether diagnostic CSF studies are also planned. Include any factors affecting procedural complexity such as prior LP difficulty, spinal abnormalities, or history of post-dural puncture headache.] (Do not infer indication from protocol names alone.)

Pre-Procedure Verification

(If any element was not obtained or not applicable, document the reason rather than leaving blank.)

• Contraindication screening: [No concerns / Concerns present: (specify signs of elevated ICP, focal neurologic deficits, local infection at site, or other)]
• Bleeding risk review: [Anticoagulant/antiplatelet status and last doses] ; [Recent platelet count if clinically indicated: value and date / Not indicated]
• Allergies confirmed: [Local anesthetics, antiseptics, and planned chemotherapy agent(s) — list any relevant allergies or "none known"]
• Intrathecal chemotherapy verification: [Agent(s), dose(s), and route verified against order] ; [Independent double-check performed per institutional policy: Yes / No (reason)]
• Time-out performed: [Two patient identifiers confirmed; procedure confirmed as LP with intrathecal chemotherapy; site confirmed as lumbar; IT drug(s)/dose(s)/route confirmed]

Consent

Informed consent obtained from [patient / authorized representative] for lumbar puncture and intrathecal medication administration, including discussion of risks (pain, bleeding, infection, CSF leak, post-dural puncture headache, nerve irritation, medication-related neurotoxicity), benefits, and alternatives. [Signed consent on file / Verbal consent obtained (reason)].

Anesthesia

Local anesthetic: [Agent], [concentration], [volume], [method of administration]. [Topical anesthetic: agent used / none].

(Include sedation documentation only if procedural sedation beyond local anesthesia was administered; otherwise omit entirely.)

Sedation: [Intended sedation level] ; [Sedation provider] ; [Dedicated monitor present] ; [Medication(s) with dose/route/time] ; [Monitoring used] ; [Complications: none / describe] ; [Recovery criteria met: yes].

Procedure Details

• Approach: [Midline / Paramedian]
• Level: [Intended interspace] → [Actual interspace]
• Skin prep: [Antiseptic used]; sterile drape applied
• Sterile technique: Sterile gloves, mask worn per CDC spinal injection guidelines
• Guidance: [None / Ultrasound / Fluoroscopy / CT]
• Needle: [Atraumatic / Cutting], [gauge], [length]; [Introducer: used / not used]
• Attempts: [Number of skin punctures]; [Number of redirections] (If multiple, briefly note reason.)
• Opening pressure: [Value in cm H2O, measured in lateral decubitus with manometer / Not obtained (reason)]

(If the procedure was unsuccessful or aborted, document the step at which it failed, the reason, and the plan for next steps. Do not document intrathecal chemotherapy as administered unless it was actually given.)

CSF Findings

(Include this section only if diagnostic studies were sent or CSF appearance was notable. Omit entirely if no CSF was collected.)

• Appearance: [Clear / Blood-tinged / Xanthochromic / Other]
• Total volume removed: [mL]
• Studies ordered: [List studies]

Intrathecal Chemotherapy Administration

(Explicitly document each item; do not reference "per orders" without specifying agent, dose, volume, and route.)

• Agent(s): [Generic name(s)]
• Dose(s): [mg] (Include dose basis if protocol-based.)
• Volume: [Total mL injected]
• Diluent: [Diluent]; preservative-free confirmed
• Route: Intrathecal
• Sequence: [Order of administration if multiple agents]
• Administration: Free flow of CSF confirmed prior to injection; [Rate: slow push over X minutes]; [Patient symptoms during injection: none / radicular pain / back pressure / headache / other]

Hemostasis and Dressing

Needle removed intact. Hemostasis achieved. [Dressing type] applied. Estimated blood loss: [minimal / volume].

Complications

[None / List complications with management provided and patient response]

Post-Procedure

• Immediate status: [Tolerated well / Issues (describe)]; neurologic exam [intact / changes (describe)]; vitals [stable / abnormal (describe)]
• Observation: [Duration]; [Positioning/bedrest instructions per institutional policy]
• Return precautions reviewed: Severe or persistent headache, fever, neck stiffness, new neurologic symptoms, worsening back pain, changes at insertion site
• Disposition: [Returned to unit in stable condition / Discharged with instructions acknowledged]