Reflex pupillary dilatation in response to skin incision and alfentanil in children anaesthetized with sevoflurane: a more sensitive measure of noxious stimulation than the commonly used variables

Constant, Isabelle; Nghe, Marie-Claire; Boudet, L; Berniere, J.; Schrayer, S.; Seeman, Robert; Murat, I.

doi:10.1093/bja/ael073

Cited by 86 publications

(66 citation statements)

References 17 publications

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“…They found that in response to a noxious stimulus, pupil dilatation was more sensitive and better correlated with opioid concentrations than heart rate, blood pressure and BIS monitoring. In a similar study performed in anaesthetised children, Constant et al 14 compared changes in pupil diameter with heart rate, blood pressure and BIS monitor variation in response to a skin incision on the lower limb. Similar to the adult data,16 these investigators were able to show that the change in pupil diameter had a greater effect size than BIS variation or haemodynamic markers.…”

Section: Discussionmentioning

confidence: 99%

“…The extent of pupil dilatation can provide an index of nociceptive input via autonomic innervation of the iris muscles,14 15 while the extent of attenuation in this pupillary response during exposure to opioid analgesics can provide an index of pharmacological effect by reflecting the extent of occupancy of μ and κ opioid receptors in the central nervous system 16. Currently available handheld pupillometers are safe, well-tolerated by children, easy to use and modestly priced 17.…”

Section: Introductionmentioning

confidence: 99%

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Pupillometry: a non-invasive technique for pain assessment in paediatric patients

Connelly

Brown

Kearns

et al. 2014

Archives of Disease in Childhood

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Objective Pupillometry has been used to assess both pain intensity and response to analgesic medications in adults. The aim of this observational study was to explore proof-of-concept for the use of this technique in paediatric patients. Changes in pupil parameters before and after opioid exposure also were evaluated. Design and Setting This was a single-center, prospective study conducted at an academic paediatric medical center. Patients Children 9-17 years of age undergoing elective surgical correction of pectusexcavatum were enrolled into a protocol approved by the human ethical committee (IRB). Interventions Pupil size and reactivity were measured using a hand-held pupillometer. Pain was assessed using age-appropriate, validated pain self-report scales. Results Thirty patients were enrolled. Each point change on a 10 cm visual analog pain intensity scale was associated with a statistically significant mean change of 0.11 mm/s in maximum pupil constriction velocity, and of approximately 0.4% in pupil diameter. As expected, there was an association between total opioid dose (expressed as morphine equivalents) and pupil diameter. Age, sex, and baseline anxiety scores did not correlate significantly with pupillary response. Conclusion The association of both maximum pupillary constriction velocity and diameter with pain scores illustrates the potential for using pupillometry as a non-invasive method to objectively quantitate pain response/intensity in children. The technique holds promise as a pharmacodynamic “tool” to assess opioid response in paediatric patients.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Pupillometry: a non-invasive technique for pain assessment in paediatric patients

Connelly

Brown

Kearns

et al. 2014

Archives of Disease in Childhood

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show abstract

“…By incorporating a tetanic stimulator with the pupillometer, we were able to accurately record a 10 second time course of pupil diameter changes in response to a standardized painful stimulus. PDR has been mostly studied on anesthetized patients and had been shown to be a useful tool to predict the level of analgesia [9]. PDR had also been used to check the level of an epidural analgesia during general anesthesia [29].…”

Section: Discussionmentioning

confidence: 99%

“…Constant et al . [9] confirm that PDR is an earlier and more sensitive response predictor of analgesia than the hemodynamic changes or the bispectral index (BIS) in children under general anesthesia. In the immediate postoperative period, the PDR is significantly correlated with the verbal rating scale [10].…”

Section: Introductionmentioning

confidence: 99%

Pupillary reflex measurement predicts insufficient analgesia before endotracheal suctioning in critically ill patients

et al. 2013

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IntroductionThis study aimed to evaluate the pupillary dilatation reflex (PDR) during a tetanic stimulation to predict insufficient analgesia before nociceptive stimulation in the intensive care unit (ICU).MethodsIn this prospective non-interventional study in a surgical ICU of a university hospital, PDR was assessed during tetanic stimulation (of 10, 20 or 40 mA) immediately before 40 endotracheal suctionings in 34 deeply sedated patients. An insufficient analgesia during endotracheal suction was defined by an increase of ≥1 point on the Behavioral Pain Scale (BPS).ResultsA total of 27 (68%) patients had insufficient analgesia. PDR with 10 mA, 20 mA and 40 mA stimulation was higher in patients with insufficient analgesia (P <0.01). The threshold values of the pupil diameter variation during a 10, 20 and 40 mA tetanic stimulation to predict insufficient analgesia during an endotracheal suctioning were 1, 5 and 13% respectively. The areas (95% confidence interval) under the receiver operating curve were 0.70 (0.54 to 0.85), 0.78 (0.61 to 0.91) and 0.85 (0.721 to 0.954) with 10, 20 and 40 mA tetanic stimulations respectively. A sensitivity analysis using the Richmond Agitation Sedation Scale (RASS) confirmed the results. The 40 mA stimulation was poorly tolerated.ConclusionsIn deeply sedated mechanically ventilated patients, a pupil diameter variation ≥5% during a 20 mA tetanic stimulation was highly predictable of insufficient analgesia during endotracheal suction. A 40 mA tetanic stimulation is painful and should not be used.

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“…The review will be limited to electroencephalogram (EEG)-derived devices. There are other ways to assess anaesthetic depth [12], but the EEG has been the focus of the overwhelming majority of research and publications in recent years. The review will approach the topic from a clinical perspective.…”

Section: Introductionmentioning

confidence: 99%

Monitoring the anaesthetic depth in children – an update

Davidson

2007

Current Opinion in Anaesthesiology

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Reflex pupillary dilatation in response to skin incision and alfentanil in children anaesthetized with sevoflurane: a more sensitive measure of noxious stimulation than the commonly used variables

Abstract: PD is a more sensitive measure of noxious stimulation than the commonly used variables of heart rate, arterial blood pressure and BIS in children anaesthetized with sevoflurane.

Cited by 86 publications

References 17 publications

Pupillometry: a non-invasive technique for pain assessment in paediatric patients

Pupillometry: a non-invasive technique for pain assessment in paediatric patients

Pupillary reflex measurement predicts insufficient analgesia before endotracheal suctioning in critically ill patients

Monitoring the anaesthetic depth in children – an update

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