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

Abstract

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.

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

“…Recently, NPi was reported to show a high specificity in predicting poor neurological outcome in a large multicenter study [12]. Although the algorithm of NPi calculation is not disclosed, it is composed of several pupillary parameters showing high correlation with PLR.…”

Geographical Differences and the National Meeting Effect in Patients with Out-of-Hospital Cardiac Arrests: A JCS–ReSS Study Report

“…First, a weak point of this study was the lack of data on in-hospital treatment, including whether extracorporeal CPR, percutaneous coronary intervention, and therapeutic hypothermia management were performed, which are relevant clinical factors that could affect patient outcomes [25][26][27]. Second, prognostic factors after hospital arrival, such as lactate clearance, pupillary light reflex, or pattern of amplitude-integrated electroencephalography, were unavailable [28][29][30]. Third, we could not assess detailed information on the difference in medical staff or organization of resuscitation teams at each hospital among the three groups, considering whether the meeting had been held in the Tokyo metropolitan area or other areas.…”

Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient

“…One multicenter study recently compared quantitative automated pupillary light reflex and neurological pupillary index (NPi; using the NeurOptics NPi-200, NeurOptics, Laguna Hills, CA) to manual pupillary light reflex in comatose cardiac arrest patients and found that an NPi ≤2, performed between days 1 and 3 following cardiac arrest, was 100% specific for an unfavorable 3-month neurological outcome when compared to manual pupillary light reflex [7].…”