Effects of Osmotic Therapy on Pupil Reactivity: Quantification Using Pupillometry in Critically Ill Neurologic Patients

Ong, Charlene; Hutch, Meghan R.; Barra, Megan E.; Kim, A.; Zafar, Sahar F.; Smirnakis, Stelios M.

doi:10.1007/s12028-018-0620-y

Cited by 40 publications

(28 citation statements)

References 35 publications

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“…The majority of pupillometry studies was single-centered, included a relatively small sample size, and focused exclusively on the pupillary size, percentage pupillary constriction, and constriction velocity [15,22,23]. Two studies examined the relationship between elevated ICP and the NPi [4], as well as the dynamic response of the NPi to ICP therapy with osmotic agents [16]. Both studies had larger sample sizes but analyzed a heterogeneous group of acute brain injury patients (including TBI, intracerebral hemorrhage, and subarachnoid hemorrhage).…”

Section: Discussionmentioning

confidence: 99%

“…An observational study in patients with normal ICP showed that standard measurements of pupillary function may be inaccurate in correctly detecting the strength of pupillary light reactivity when compared to quantitative, automated infrared pupillometers [10]. Emerging data also suggest that quantitative pupillometry may be helpful in detecting intracranial midline shift [15] and in monitoring the effects of ICP osmotic therapy on pupillary function [16].…”

Section: Introductionmentioning

confidence: 99%

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Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

et al. 2019

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Background: Elevated intracranial pressure (ICP) is frequent after traumatic brain injury (TBI) and may cause abnormal pupillary reactivity, which in turn is associated with a worse prognosis. Using automated infrared pupillometry, we examined the relationship between the Neurological Pupil index (NPi) and invasive ICP in patients with severe TBI. Methods: This was an observational cohort of consecutive subjects with severe TBI (Glasgow Coma Scale [GCS] < 9 with abnormal lesions on head CT) who underwent parenchymal ICP monitoring and repeated NPi assessment with the NPi-200® pupillometer. We examined NPi trends over time (four consecutive measurements over intervals of 6 h) prior to sustained elevated ICP > 20 mmHg. We further analyzed the relationship of cumulative abnormal NPi burden (%NPi values < 3 during total ICP monitoring time) with intracranial hypertension (ICHT)-categorized as refractory (ICHT-r; requiring surgical decompression) vs. non-refractory (ICHT-nr; responsive to medical therapy)-and with the 6-month Glasgow Outcome Score (GOS). Results: A total of 54 patients were studied (mean age 54 ± 21 years, 74% with focal injuries on CT), of whom 32 (59%) had ICHT. Among subjects with ICHT, episodes of sustained elevated ICP (n = 43, 172 matched ICP-NPi samples; baseline ICP [T − 6 h ] 14 ± 5 mmHg vs. ICPmax [T 0 h ] 30 ± 9 mmHg) were associated with a concomitant decrease of the NPi (baseline 4.2 ± 0.5 vs. 2.8 ± 1.6, p < 0.0001 ANOVA for repeated measures). Abnormal NPi values were more frequent in patients with ICHT-r (n = 17; 38 [3-96]% of monitored time vs. 1 [0-9]% in patients with ICHT-nr [n = 15] and 0.5 [0-10]% in those without ICHT [n = 22]; p = 0.007) and were associated with an unfavorable 6-month outcome (15 [1-80]% in GOS 1-3 vs. 0 [0-7]% in GOS 4-5 patients; p = 0.002). Conclusions: In a selected cohort of severe TBI patients with abnormal head CT lesions and predominantly focal cerebral injury, elevated ICP episodes correlated with a concomitant decrease of NPi. Sustained abnormal NPi was in turn associated with a more complicated ICP course and worse outcome.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

et al. 2019

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“…Preliminary studies conducted in intensive care units reported the usefulness of QP for detecting a wide range of conditions including increased intracranial pressure [7][8][9][10]. response to osmotherapy [27], discrimination between compressive lesions and microvascular ischemic oculomotor nerve palsy [28], assessment of disease severity of aneurysmal subarachnoid hemorrhage [29], the depth of sedation and analgesia [30], and neurological prognostication in comatose resuscitation-of-spontaneous-circulation following cardiac arrest [11][12][13][14][15][16][17]. The prognostic implication of QP has been only investigated in patients with cardiac arrest [11][12][13][14][15][16][17], in whom a decrease in NPi values less than 2.0 was associated with unfavorable neurological outcomes [13].…”

Section: Discussionmentioning

confidence: 99%

Quantitative Assessments of Pupillary Light Reflexes in Hospital-Onset Unconsciousness

Lee

Choi

Park

et al. 2020

Preprint

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BackgroundPatients who develop hospital-onset unconsciousness should be promptly managed in order to avoid clinical deterioration. Pupillary examination through pupillary light reflex is the mainstay method in the initial evaluation of unconscious patients, but the current method of light shedding and subjective description often shows poor reliability. The objective of this study is to explore whether a quantitative measurement of pupillary light reflexes is useful in detecting brain herniation syndrome and predicting neurological outcomes in non-neurological patients who developed hospital-onset unconsciousness.MethodsThis was a registry-based observational study on patients who activated the neurological rapid response team at Asan Medical Center (Seoul, Korea). Hospital-onset unconsciousness was defined as a newly developed stupor or comatose state during admission. Demographics, comorbidities, pupillometry parameters including Neurological Pupil index, brain herniation syndrome, in-hospital mortality, and modified Rankin Scale at 3-months were analyzed.ResultsIn 214 consecutive patients with hospital-onset unconsciousness, 37 (17%) had brain herniation syndrome. The optimal cut-off value of Neurological Pupil index for detecting brain herniation syndrome was < 1.6 (specificity, 91% [95% confidence interval (CI) = 86−95]; sensitivity, 49% [95% CI = 32−66]). The in-hospital mortality rate was 28% (59/214); the Neurological Pupil index was negatively associated with in-hospital mortality after adjustments for the presence of brain herniation syndrome (adjusted odds ratio = 0.77, 95% CI = 0.62–0.96). Poor neurological outcomes (modified Rankin Scale ≥ 4) at 3 months was observed in 76% (152/201) of the patients; the Neurological Pupil index was negatively associated with poor neurological outcomes after adjustments for clinical variables (adjusted odds ratio = 0.67, 95% CI = 0.49–0.90). ConclusionsQuantitative measurements of pupillary light reflexes may be useful for early detection of potentially life-threatening neurological conditions in patients with hospital-onset unconsciousness.

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“…Intracranial hypertension is associated with decreased NPi, and patients with elevated ICP had an improvement in NPi values after treatment with osmotic therapy. Therefore, pupillometry has the potential as a noninvasive tool to assess the efficacy of osmotic therapy [12].…”

Section: Traumatic Brain Injurymentioning

confidence: 99%

Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient

2020

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Effects of Osmotic Therapy on Pupil Reactivity: Quantification Using Pupillometry in Critically Ill Neurologic Patients

Cited by 40 publications

References 35 publications

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

Quantitative Assessments of Pupillary Light Reflexes in Hospital-Onset Unconsciousness

Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient

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