If I can’t get it lying down, I have never seen benefit from sitting the patient up. But that is just me, I know for some folks sitting the pt up makes things much easier. I usually grab ultrasound in this situation. Also, if I am hitting ligaments that feel like bones, I use para-median approach. To answer you question, the seated pressure will be changed by the height of the CSF column from the patient’s brain to you needle; you can’t correct for this. If you were able to support the needle and lay the patient down, it would be accurate, but I would be scared of the needle moving in the process. I think in this case you just accept that you will not get an opening pressure.

i roll them on their side, move their legs way up in to fetal position and then put the bed rail back up. This keeps their knees from falling down. I then loop a sheet around their knees and tie it high up on the bed rail. Mech vent should not sig. affect the opening pressure, unless the PEEP is crazy high.

Kurt,

I’d love to see the article when it is actually published, but I think the authors have only published the abstract. They derived the correction formula retrospectively; it needs to be prospectively validated before prime time use.

Studies of second- and third-generation cephalosporins show no increase in allergic reactions in patients who have a history of penicillin allergy (Ann Allergy Asthma Immunol 1995;74(2)) AAP cephalosporins in the pen allergic patient (Pediatrics 2005;115(4):1048) From EMEDHome: Prescribing Cephalosporins in the Setting of a Penicillin Allergy: What is the Truth? Conventional wisdom holds that there is a significant risk of an allergic reaction if a cephalosporin is prescribed to a patient with a history of a PCN allergy (2007 PDR: “cross-hypersensitivity among beta-lactam antibiotics has been clearly documented and may occur in up to 10% of patients with a history of penicillin allergy”). Key Background Facts: * Early studies on this topic were very flawed because the penicillin test compounds had been contaminated with cephalosporins; until 1982, penicillin was produced commercially using the cephalsoporium mold (1,2). Furthermore, these early studies upon which the frequently quoted 10% cross-reactivity is based did not routinely confirm the allergy by skin testing, and at least some of the reactions were not immune-mediated (3). * When patients with a history of PCN allergy receive 1st generation cephalosporins – which share a side chain similar to penicillin – they may exhibit an increased risk of an… Read more »

untreated, HSV encephalitis has a mortality of ~70%. With acyclovir it goes down to about 28%, see (N Engl J Med. 1986 Jan 16;314(3):144-9.
Vidarabine versus acyclovir therapy in herpes simplex encephalitis.) As you allude to, the earlier the better, but I had not come across the 2 day timing at all. I don’t think you will find many folks who would just treat presumed or known HSV enceph with only supportive care. So I don’t want to say the advice is bad, but I would love to see some data. : )

thanks so much for commenting. reply or email me if you have more.

scott