Opinion and Special Articles: Stress when performing the first lumbar puncture may compromise patient safety

American Academy of Neurology. Published online May 21st, 2018. DOI: https://doi.org/10.1212/WNL.0000000000005556

Mikael Johannes Vuokko HenriksenTroels WieneckeJesper KristiansenYoon Soo ParkCharlotte Ringsted and Lars Konge


Objective To quantify physician stress levels when performing lumbar puncture (LP) and explore operator stress effect on patient outcomes.

Methods This was a cross-sectional, multicenter study. Novices, intermediates, and experts in performing LP were recruited from 4 departments of neurology and emergency medicine. Stress was measured before and during performance of the LP using cognitive appraisal (CA), State-Trait Anxiety Inventory–Short (STAI-S) questionnaire, and the heart rate variability measure low frequency/high frequency index (LF/HF ratio). Patient-related outcomes were pain, confidence in the operator, and postdural puncture headache (PDPH).

Results Forty-six physicians were included in the study: 22 novices, 12 intermediates, and 12 experts. Novices had the highest stress level and experts the lowest measured by cognitive appraisal and STAI-S before and during LP performance (p < 0.001 for all comparisons). Novices had the highest sympathetic tonus indicated by the highest LF/HF ratio before (p = 0.004) and during (p = 0.056) LP performance. Physician stress level was not significantly related to patients’ pain. However, there was a significant relationship between STAI-S during the procedure and patient confidence in the operator (regression coefficient = −0.034, p = 0.008). High physician heart rate during the procedure significantly increased the odds of PDPH (odds ratio = 1.17, p = 0.036).

Conclusion Novice stress levels were high before and during performance of LP. Stress was significantly related to patient confidence in the operator and risk of PDPH. Simulation-based training should be considered to reduce novice residents’ stress levels and increase patient safety.