Neonatal Intensive Care Unit, Department Mother and Child, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
Paediatrics, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden.
Cochrane Database Syst Rev. 2023 Oct 23;10(10):CD015592. doi: 10.1002/14651858.CD015592.pub2.
Lumbar puncture is a common invasive procedure performed in newborns for diagnostic and therapeutic purposes. Approximately one in two lumbar punctures fail, resulting in both short- and long-term negative consequences for the clinical management of patients. The most common positions used to perform lumbar puncture are the lateral decubitus and sitting position, and each can impact the success rate and safety of the procedure. However, it is uncertain which position best improves patient outcomes.
To assess the benefits and harms of the lateral decubitus, sitting, and prone positions for lumbar puncture in newborn infants.
We used standard, extensive Cochrane search methods. The latest search date was 24 January 2023.
We included randomized controlled trials (RCTs) and quasi-RCTs involving newborn infants of postmenstrual age up to 46 weeks and 0 days, undergoing lumbar puncture for any indication, comparing different positions (i.e. lateral decubitus, sitting, and prone position) during the procedure.
We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) and risk difference (RD) for dichotomous data and mean difference (MD) and standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CI). Our primary outcomes were successful lumbar puncture procedure at the first attempt; total number of lumbar puncture attempts; and episodes of bradycardia. We used GRADE to assess the certainty of evidence for each outcome.
We included five studies with 1476 participants. Compared to sitting position: lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at the first attempt (RR 0.93, 95% CI 0.85 to 1.02; RD -0.04, 95% CI -0.09 to 0.01; I = 70% and 72% for RR and RD, respectively; 2 studies, 1249 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts. Lateral decubitus position likely increases episodes of bradycardia (RR 1.72, 95% CI 1.08 to 2.76; RD 0.03, 95% CI 0.00 to 0.05; number needed to treat for an additional harmful outcome (NNTH) = 33; I = not applicable and 69% for RR and RD, respectively; 3 studies, 1279 infants, moderate-certainty evidence) and oxygen desaturation (RR 2.10, 95% CI 1.42 to 3.08; RD 0.06, 95% CI 0.03 to 0.09; NNTH = 17; I = not applicable and 96% for RR and RD, respectively; 2 studies, 1249 infants, moderate-certainty evidence). The evidence is very uncertain regarding the effect of lateral decubitus position on time to perform the lumbar puncture (MD 2.00, 95% CI -4.98 to 8.98; I = not applicable; 1 study, 20 infants, very low-certainty evidence). Lateral decubitus position may result in little to no difference in the number of episodes of apnea during the procedure (RR not estimable; RD 0.00, 95% CI -0.03 to 0.03; I = not applicable and 0% for RR and RD, respectively; 2 studies, 197 infants, low-certainty evidence). No studies reported apnea defined as number of infants with one or more episodes during the procedure. Compared to prone position: lateral decubitus position may reduce successful lumbar puncture procedure at first attempt (RR 0.75, 95% CI 0.63 to 0.90; RD -0.21, 95% CI -0.34 to -0.09; number needed to treat for an additional beneficial outcome = 5; I = not applicable; 1 study, 171 infants, low-certainty evidence). None of the studies reported the total number of lumbar puncture attempts or episodes of apnea. Pain intensity during and after the procedure was reported using a non-validated pain scale. None of the studies comparing lateral decubitus versus prone position reported the other critical outcomes of this review.
AUTHORS' CONCLUSIONS: When compared to sitting position, lateral decubitus position may result in little to no difference in successful lumbar puncture procedure at first attempt. None of the included studies reported the total number of lumbar puncture attempts. Furthermore, infants in a lateral decubitus position likely experience more episodes of bradycardia and oxygen desaturation, and there may be little to no difference in episodes of apnea. The evidence is very uncertain regarding time to perform lumbar puncture. Pain intensity during and after the procedure was reported using a pain scale that was not included in our prespecified tools for pain assessment due to its high risk of bias. Most study participants were term newborns, thereby limiting the applicability of these results to preterm babies. When compared to prone position, lateral decubitus position may reduce successful lumbar puncture procedure at first attempt. Only one study reported on this comparison and did not evaluate adverse effects. Further research exploring harms and benefits and the effect on patients' pain experience of different positions during lumbar puncture using validated pain scoring tool may increase the level of confidence in our conclusions.
腰椎穿刺是一种常见的侵入性操作，用于新生儿的诊断和治疗目的。大约有一半的腰椎穿刺会失败，这对患者的临床管理产生了短期和长期的负面影响。最常使用的进行腰椎穿刺的体位是侧卧位和坐位，每种体位都可能影响操作的成功率和安全性。然而，目前尚不确定哪种体位能最好地改善患者的预后。
评估新生儿行腰椎穿刺时采用侧卧位、坐位和俯卧位的利弊。
我们使用了标准的、广泛的 Cochrane 检索方法。最新检索日期为 2023 年 1 月 24 日。
我们纳入了随机对照试验（RCT）和准随机对照试验，涉及到胎龄达到 46 周及 0 天以内的新生儿，因任何适应证行腰椎穿刺，比较不同体位（即侧卧位、坐位和俯卧位）在操作过程中的差异。
我们使用了标准的 Cochrane 方法。我们使用固定效应模型，采用比值比（RR）和风险差（RD）表示二分类数据，采用均数差（MD）和标准化均数差（SMD）表示连续数据，并报告其 95%置信区间（CI）。我们的主要结局是首次尝试时成功进行腰椎穿刺的程序；总腰椎穿刺次数；以及心动过缓的发作次数。我们使用 GRADE 评估每个结局的证据确定性。
我们纳入了 5 项研究，共涉及 1476 名参与者。与坐位相比：侧卧位可能对首次尝试时成功进行腰椎穿刺的程序没有明显影响（RR 0.93，95%CI 0.85 至 1.02；RD -0.04，95%CI -0.09 至 0.01；RR 和 RD 的 I²分别为 70%和 72%；2 项研究，1249 名婴儿，低确定性证据）。没有研究报告总的腰椎穿刺次数。侧卧位可能增加心动过缓的发作次数（RR 1.72，95%CI 1.08 至 2.76；RD 0.03，95%CI 0.00 至 0.05；增加一个不良结局的需要治疗人数（NNTH）=33；RR 和 RD 的 I²分别为不适用和 69%；3 项研究，1279 名婴儿，中等确定性证据）和氧饱和度下降（RR 2.10，95%CI 1.42 至 3.08；RD 0.06，95%CI 0.03 至 0.09；NNTH=17；RR 和 RD 的 I²分别为不适用和 96%；2 项研究，1249 名婴儿，中等确定性证据）。关于侧卧位对腰椎穿刺时间的影响，证据非常不确定（MD 2.00，95%CI -4.98 至 8.98；I²不适用；1 项研究，20 名婴儿，极低确定性证据）。侧卧位可能对操作过程中呼吸暂停的发作次数没有明显影响（RR 无法估计；RD 0.00，95%CI -0.03 至 0.03；RR 和 RD 的 I²分别为不适用和 0%；2 项研究，197 名婴儿，低确定性证据）。没有研究报告定义为在操作过程中有一次或多次呼吸暂停的婴儿数量。与俯卧位相比：侧卧位可能降低首次尝试时成功进行腰椎穿刺的程序（RR 0.75，95%CI 0.63 至 0.90；RD -0.21，95%CI -0.34 至 -0.09；增加一个有益结局的需要治疗人数=5；I²不适用；1 项研究，171 名婴儿，低确定性证据）。没有研究报告总的腰椎穿刺次数或呼吸暂停的发作次数。操作过程中和操作后疼痛强度使用非验证性疼痛量表进行报告。比较侧卧位与俯卧位的研究中，没有一项报告本综述的其他关键结局。
与坐位相比，侧卧位可能对首次尝试时成功进行腰椎穿刺的程序没有明显影响。没有研究报告总的腰椎穿刺次数。此外，处于侧卧位的婴儿可能经历更多的心动过缓和氧饱和度下降，并且呼吸暂停的发作次数可能没有明显差异。关于腰椎穿刺时间的证据非常不确定。操作过程中和操作后疼痛强度使用的疼痛量表存在高偏倚风险，因此未包含在我们的疼痛评估工具中。大多数研究参与者是足月新生儿，因此这些结果对早产儿的适用性有限。与俯卧位相比，侧卧位可能降低首次尝试时成功进行腰椎穿刺的程序。仅有 1 项研究对此进行了比较，并未评估不良影响。进一步研究可能会探索不同体位在腰椎穿刺过程中的利弊和对患者疼痛体验的影响，使用验证过的疼痛评分工具可能会提高我们结论的可信度。
