Early prediction of coma recovery after cardiac arrest with blinded pupillometry

Solari, Daria; Rossetti, Andrea O.; Carteron, Laurent; Miroz, John‐Paul; Nový, Jan; Eckert, Philippe; Oddo, Mauro

doi:10.1002/ana.24943

Cited by 89 publications

(64 citation statements)

References 30 publications

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“…Preliminary single-center studies, evaluating the value of quantitative pupillometry, focused exclusively on the qPLR and found variable cut-offs of 100% specificity for poor prognosis, with thresholds varying from 10% [16] to 13% [17, 18]. These studies used other devices that did not compute automated NPi.…”

Section: Discussionmentioning

confidence: 99%

Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study

et al. 2018

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PurposeTo assess the ability of quantitative pupillometry [using the Neurological Pupil index (NPi)] to predict an unfavorable neurological outcome after cardiac arrest (CA).MethodsWe performed a prospective international multicenter study (10 centers) in adult comatose CA patients. Quantitative NPi and standard manual pupillary light reflex (sPLR)—blinded to clinicians and outcome assessors—were recorded in parallel from day 1 to 3 after CA. Primary study endpoint was to compare the value of NPi versus sPLR to predict 3-month Cerebral Performance Category (CPC), dichotomized as favorable (CPC 1–2: full recovery or moderate disability) versus unfavorable outcome (CPC 3–5: severe disability, vegetative state, or death).ResultsAt any time between day 1 and 3, an NPi ≤ 2 (n = 456 patients) had a 51% (95% CI 49–53) negative predictive value and a 100% positive predictive value [PPV; 0% (0–2) false-positive rate], with a 100% (98–100) specificity and 32% (27–38) sensitivity for the prediction of unfavorable outcome. Compared with NPi, sPLR had significantly lower PPV and significantly lower specificity (p < 0.001 at day 1 and 2; p = 0.06 at day 3). The combination of NPi ≤ 2 with bilaterally absent somatosensory evoked potentials (SSEP; n = 188 patients) provided higher sensitivity [58% (49–67) vs. 48% (39–57) for SSEP alone], with comparable specificity [100% (94–100)].ConclusionsQuantitative NPi had excellent ability to predict an unfavorable outcome from day 1 after CA, with no false positives, and significantly higher specificity than standard manual pupillary examination. The addition of NPi to SSEP increased sensitivity of outcome prediction, while maintaining 100% specificity.Electronic supplementary materialThe online version of this article (10.1007/s00134-018-5448-6) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study

et al. 2018

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“…1. In the subset of patients in whom pupillometry measurements were performed at days 6 and 7 (n = 30), q-PLR remained significantly lower in patients with delirium (median 22 [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] vs. 30 [29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] in non-delirious patients at day 6, and 27 [25][26][27][28][29][30][31] vs. 35 [27][28][29][30][31][32][33][34][35][36][37][38] at day 7; both p < 0.05).…”

Section: Associations Between Icu Delirium and Quantitative Pupillarymentioning

confidence: 99%

Neuromonitoring of delirium with quantitative pupillometry in sedated mechanically ventilated critically ill patients

et al. 2020

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Background: Intensive care unit (ICU) delirium is a frequent secondary neurological complication in critically ill patients undergoing prolonged mechanical ventilation. Quantitative pupillometry is an emerging modality for the neuromonitoring of primary acute brain injury, but its potential utility in patients at risk of ICU delirium is unknown. Methods: This was an observational cohort study of medical-surgical ICU patients, without acute or known primary brain injury, who underwent sedation and mechanical ventilation for at least 48 h. Starting at day 3, automated infrared pupillometry-blinded to ICU caregivers-was used for repeated measurement of the pupillary function, including quantitative pupillary light reflex (q-PLR, expressed as % pupil constriction to a standardized light stimulus) and constriction velocity (CV, mm/s). The relationship between delirium, using the CAM-ICU score, and quantitative pupillary variables was examined. Results: A total of 59/100 patients had ICU delirium, diagnosed at a median 8 (5-13) days from admission. Compared to non-delirious patients, subjects with ICU delirium had lower values of q-PLR (25 [19-31] vs. 20 [15-28] %) and CV (2.5 [1.7-2.8] vs. 1.7 [1.4-2.4] mm/s) at day 3, and at all additional time-points tested (p < 0.05). After adjusting for the SOFA score and the cumulative dose of analgesia and sedation, lower q-PLR was associated with an increased risk of ICU delirium (OR 1.057 [1.007-1.113] at day 3; p = 0.03). Conclusions: Sustained abnormalities of quantitative pupillary variables at the early ICU phase correlate with delirium and precede clinical diagnosis by a median 5 days. These findings suggest a potential utility of quantitative pupillometry in sedated mechanically ventilated ICU patients at high risk of delirium.

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“…In the last several years, quantitative assessment of pupillary light reflex (PLR) has emerged as a promising modality for predicting neurological outcomes in post-CA patients. Several publications reported the prognostic superiority of the quantitative assessment of PLR over the qualitative evaluation of PLR before 72 h after CA [5][6][7][8][9]. Recently, we have reported that quantitative values of PLR in survivors or in patients with favorable neurological outcomes were consistently greater than values in non-survivors or in patients with unfavorable outcomes, respectively, within 72 h following the return of spontaneous circulation (ROSC) after OHCA [9].…”

Section: Introductionmentioning

confidence: 99%

Early outcome prediction with quantitative pupillary response parameters after out-of-hospital cardiac arrest: A multicenter prospective observational study

et al. 2020

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We aimed to determine the characteristics of quantitative pupillary response parameters other than amplitude of pupillary light reflex (PLR) early after return of spontaneous circulation (ROSC) and their implications for predicting neurological outcomes early after cardiac arrest (CA). Fifty adults resuscitated after non-traumatic out-of-hospital CA from four emergency hospitals were enrolled. Pupil diameters, PLR, constriction velocity (CV), maximum CV (MCV), dilation velocity (DV), latency of constriction, and Neurological Pupil index (NPi) were quantitatively measured at 0, 6, 12, 24, 48, and 72 h post-ROSC using an automated pupillometer. Change over time of each parameter was compared between favorable (Cerebral Performance Category [CPC] 1 or 2) and unfavorable neurological outcome (CPC 3-5) groups. Prognostic values of 90-day favorable outcome by these parameters and when combined with clinical predictors (witness status, bystander cardiopulmonary resuscitation, initial shockable rhythm, implementation of target temperature management) were tested. Thirteen patients achieved favorable outcome. CV, MCV, DV (P < 0.001), and NPi (P = 0.005) were consistently greater in the favorable group than in the unfavorable outcome group. Change over time was not statistically different between the groups in all parameters. CV, MCV, DV (ρ = 0.96 to 0.97, P < 0.001, respectively), and NPi (ρ = 0.65, P < 0.001) positively correlated with PLR. The prognostic value of 0-hour CV (area under the curve, AUC [95% confidence interval]: 0.92 [0.80-1.00]), , and NPi (0.88 [0.74-1.00]) was equivalent to that of . Prognostic values improved to AUC of 0.95-0.96 when 0hour PLR, CV, DV, or NPi was combined with clinical predictors. The 0-hour CV, MCV, and NPi showed equivalent prognostic values to PLR alone/in combination with clinical predictors. Using PLR among several quantitative pupillary response parameters for early neurological prognostication of post-CA patients is a simple and effective strategy.

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Early prediction of coma recovery after cardiac arrest with blinded pupillometry

Cited by 89 publications

References 30 publications

Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study

Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study

Neuromonitoring of delirium with quantitative pupillometry in sedated mechanically ventilated critically ill patients

Early outcome prediction with quantitative pupillary response parameters after out-of-hospital cardiac arrest: A multicenter prospective observational study

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Early prediction of coma recovery after cardiac arrest with blinded pupillometry

Cited by 89 publications

References 30 publications

Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study

Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study

Neuromonitoring of delirium with quantitative pupillometry in sedated mechanically ventilated critically ill patients

Early outcome prediction with quantitative pupillary response parameters after out-of-hospital cardiac arrest: A multicenter prospective observational study​

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Early outcome prediction with quantitative pupillary response parameters after out-of-hospital cardiac arrest: A multicenter prospective observational study