Integrating Quantitative Pupillometry Into Regular Care in a Neurotrauma Intensive Care Unit

Abstract

In the setting of acute traumatic brain injury (TBI), an abnormal pupil assessment may suggest a worsening intracranial lesion. Early detection of pupillary changes may expedite emergent care to improve outcomes. Automated, handheld pupillometers have been commercially available for 20 years, and several studies suggest that their use may facilitate early recognition of worsening injury and intracranial hypertension. The use of pupillometry as a bedside tool in the routine care of patients with severe TBI (Glasgow Coma Scale score ≤ 8) has not been described. We performed a quality improvement project to implement routine use of quantitative pupillometry in our neurotrauma intensive care unit. Nursing staff were trained on device use and the project's aims in a 30-minute in-service session. Nurses caring for severe TBI patients completed standard pupil assessments using (a) a flashlight and (b) a pupillometer to quantify pupil size and reactivity (Neurological Pupil index) every hour. Abnormal results were reported to on-call providers. We administered surveys to evaluate knowledge, practical use of the pupillometer data, and satisfaction with the device every 3 months. Data were available for 22 nurses at 4 separate time points. Staff were positive about their ability to use and understand the device (µ = 8.7 and 9.1, respectively, on a 10-point scale) and reported that it added value to patient care and critical decision-making. Use of automated pupillometry is acceptable to nursing staff in a neurotrauma intensive care unit, and staff believed that pupillometry results enhanced clinical decision-making.

Pupillometry in neurocritical care

“…Conversely, other studies have used pupillometers for specific patient populations, such as those with severe traumatic brain injuries or aneurysmal subarachnoid hemorrhage. 8,9 Those patients who could potentially benefit from objective pupillometry, such as those at greatest risk for herniation, are not always the population selected in our neurocritical care unit. Previous studies failed to provide recommendations for which patient populations benefit from pupillometer use.…”

“…The pupillometer provides objective measures during a pupillary assessment 4,5. This device provides data on the size of pupils and calculates a neurologic pupillary index (NPi), which compares pupil measurements against a normative model of pupil reaction to light.…”

Quantitative Pupillometry in the Intensive Care Unit

“…A single-center evaluation of nursing colleagues found a preference for the pupillometer over the standard flashlight pupil assessment, herein referred to as qualitative pupillometry. 21 Nevertheless, there are technical limitations to consider. Agitated or confused patients can be difficult to evaluate.…”

The effect evaluation of advanced penlight

“…Pupil size and reactivity assessment is a regular health and nursing care in general ward, emergency room (ER), and intensive care unit (ICU) [ 1 – 2 ]. Measuring pupillary contraction and change of size after light stimulation can serve as a window to view the brain and evaluate the function of the autonomous nervous system.…”

“…Measuring pupillary contraction and change of size after light stimulation can serve as a window to view the brain and evaluate the function of the autonomous nervous system. In addition, pupillometry can be used for early diagnosis of related diseases, to assess the severity of disease, to decide on treatment and nursing care strategy, and to predict the outcome of disease [ 1 – 8 ]. Measuring pupil diameter is also applied to study recognition memory.…”