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Zorzi S, Ayako Minemura Ordinola A, Cunha De Souza Lima E, Martins Teixeira G, Salvagno M, Sterchele ED, Taccone FS. A glimpse into multimodal neuromonitoring in acute liver failure: a case report. Ann Med Surg (Lond) 2024; 86:539-544. [PMID: 38222739 PMCID: PMC10783349 DOI: 10.1097/ms9.0000000000001519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/07/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Acute liver failure (ALF) is a rapidly progressing, life-threatening syndrome characterized by liver-related coagulopathy and hepatic encephalopathy (HE). Given that higher HE grades correlate with poorer outcomes, clinical management of ALF necessitates close neurological monitoring. The primary objective of this case report is to highlight the diagnostic value of utilizing multimodal neuromonitoring (MNM) in a patient suffering from ALF. Case report A 56-year-old male patient with a history of chronic alcoholism, without prior chronic liver disease, and recent acetaminophen use was admitted to the hospital due to fatigue and presenting with a mild flapping tremor. The primary hypothesis was an acute hepatic injury caused by acetaminophen intoxication. In the following hours, the patient's condition deteriorated, accompanied by neurological decline and rising ammonia levels. The patient's neurological status was closely monitored using MNM. Bilaterally altered pupillary light reflex assessed by decreasing in the Neurological Pupil Index values, using automated pupillometry, initially suggested severe brain oedema. However, ultrasound measurements of the optic nerve sheath diameter showed normal values in both eyes, P2/P1 noninvasive intracranial pressure waveform assessment was within normal ranges and the cerebral computed tomography-scan revealed no signs of cerebral swelling. Increased middle cerebral artery velocities measured by Transcranial Doppler and the initiation of electroencephalography monitoring yielded the presence of status epilepticus. Discussion The utilization of MNM facilitated a more comprehensive understanding of the mechanisms underlying the patient's clinical deterioration in the setting of HE. Nonetheless, future studies are needed to show feasibility and to yield valuable insights that can enhance the outcomes for patients with HE using such an approach. Given the absence of specific guidelines in this particular context, it is advisable for physicians to give further consideration to the incorporation of MNM in the management of unconscious patients with ALF.
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Affiliation(s)
- Stefano Zorzi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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Sharma R, Tsikvadze M, Peel J, Howard L, Kapoor N, Freeman WD. Multimodal monitoring: practical recommendations (dos and don'ts) in challenging situations and uncertainty. Front Neurol 2023; 14:1135406. [PMID: 37206910 PMCID: PMC10188941 DOI: 10.3389/fneur.2023.1135406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/06/2023] [Indexed: 05/21/2023] Open
Abstract
With the advancements in modern medicine, new methods are being developed to monitor patients in the intensive care unit. Different modalities evaluate different aspects of the patient's physiology and clinical status. The complexity of these modalities often restricts their use to the realm of clinical research, thereby limiting their use in the real world. Understanding their salient features and their limitations can aid physicians in interpreting the concomitant information provided by multiple modalities to make informed decisions that may affect clinical care and outcomes. Here, we present a review of the commonly used methods in the neurological intensive care unit with practical recommendations for their use.
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Affiliation(s)
- Rohan Sharma
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
- *Correspondence: Rohan Sharma
| | - Mariam Tsikvadze
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Jeffrey Peel
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Levi Howard
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Nidhi Kapoor
- Department of Neurology, Baptist Medical Center, Jacksonville, FL, United States
| | - William D. Freeman
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
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Kotani J, Nakao H, Yamada I, Miyawaki A, Mambo N, Ono Y. A Novel Method for Measuring the Pupil Diameter and Pupillary Light Reflex of Healthy Volunteers and Patients With Intracranial Lesions Using a Newly Developed Pupilometer. Front Med (Lausanne) 2021; 8:598791. [PMID: 34557496 PMCID: PMC8452878 DOI: 10.3389/fmed.2021.598791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Physicians currently measure the pupil diameter and the pupillary light reflex with visual observations using a ruler and a traditional penlight, leading to possibly inaccurate and subjective assessments. Although a mobile pupillometer has been developed and is available in clinical settings, this device can only assess one pupil at a time. Hence, an indirect pupillary light reflex, including those under irradiation to the opposite side of pupil, cannot be evaluated. Consequently, we have developed a new automatic mobile pupilometer, the Hitomiru®, with Hitomiru Co., Ltd. (Tokyo, Japan). This device is a two-glass type pupilometer with a video recording system. The pupil diameter and light reflex of both pupils can be measured simultaneously; therefore, both indirect and direct light reflexes can be assessed. Purpose: To evaluate the clinical ability of the Hitomiru® pupilometer to assess the pupil diameter and the pupillary light reflex of healthy volunteers and patients with intracranial lesions in an intensive care unit (ICU). Methods: Twenty-five healthy volunteers and five ICU patients with intracranial lesions on only the left side were assessed using the Hitomiru® pupilometer. The protocol was as follows: infrared light was applied to both pupils, followed by visible light to the right pupil, infrared light to both pupils, visible light to the left pupil, and then infrared light to both pupils. All the intervals were 2 s, and the dynamics of pupil diameters on both sides were continuously recorded. Results: The healthy adults had approximately 0.5 mm anisocoria, miosis was harder, and mydriasis was less with increased age. There were several differences in miosis rates, miosis times, and mydriasis rates between the healthy adults and the patients with intracranial lesions with both direct irradiation and indirect irradiation. Conclusions: The initial trial estimated and digitally recorded direct and indirect light reflexes, including rapidity of miosis after direct and indirect lights on, and mydriasis after direct and indirect lights off. The Hitomiru® pupilometer was a useful device to digitally record and investigate the relationship between pupil reflexes and intracranial diseases.
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Affiliation(s)
- Joji Kotani
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan.,Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Nakao
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Isamu Yamada
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan.,Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi Miyawaki
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Naomi Mambo
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuko Ono
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe, Japan
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Cortes MX, Siaron KB, Nadim HT, Ahmed KM, Romito JW. Neurological Pupil Index as an Indicator of Irreversible Cerebral Edema: A Case Series. J Neurosci Nurs 2021; 53:145-148. [PMID: 33782353 DOI: 10.1097/jnn.0000000000000584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT BACKGROUND: Assessing the pupillary light reflex is a core component of neurological assessments. Pupil size and reactivity can provide early warning about early neurological decline. Automated infrared pupillometry is noninvasive and easy to use and has greater reliability compared with manual assessments to obtain objective and consistent measurements of pupillary size and reactivity to light. METHODS: This is a case series of 3 patients who had poor baseline clinical neurological examinations. Because it would be more difficult to detect acute neurological deterioration, automated infrared pupillometry and the Neurological Pupil index (NPi) were used in addition to the clinical neurological examination. NPi values < 3.0 prompted further imaging. RESULTS: In each case, abnormal NPi values prompted emergent imaging that confirmed acute cerebral edema and resulted in a change in management and treatment plan. CONCLUSION: The automated infrared pupillometry is a noninvasive monitor that can provide additional objective data in patients with a poor baseline neurological examination in whom it may otherwise be difficult to detect neurological deterioration.
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Abstract
BACKGROUND Pupillary light reflex (PLR) has traditionally been assessed using a pen torch (light). Although the terms "brisk" or "sluggish" are often used, it is unclear what characteristics of the PLR result in this description. More recently, automated infrared pupillometry has enabled us to quantify the different components of a PLR. METHODS We conducted a 2-part questionnaire survey of pediatric intensive care unit (PICU) nurses. In part 1, nurses were requested to describe the key characteristics that they associate with a brisk or sluggish PLR in free-text responses. In part 2, after an introduction to pupillometry and the different components of a PLR, nurses were asked to rank the relative importance of latency (time taken for pupil to start reacting to light), percentage change (in pupil size after light stimulus), and constriction velocity (rate of constriction after light stimulus) in relation to a pupil being described as "brisk" and "sluggish. RESULTS Fifty nurses responded. In part 1, "Quick" was the commonest term used (36% of respondents) to describe a brisk PLR, and 72% used "slow" for a sluggish PLR. Most descriptions most closely mapped to features of latency and/or constriction velocity. In part 2, latency was ranked the most important component on pupillometry for describing brisk (32%) and sluggish (34%) PLRs. Constriction velocity was ranked as the most important by 18% (brisk) and 20% (sluggish), whereas 44% (brisk) and 46% (sluggish) ranked percentage change behind the other 2 characteristics. CONCLUSION Latency, followed by the constriction velocity, was felt by PICU nurses to be the most important characteristic of the PLR that results in terms "brisk" or "sluggish" being used at the bedside to describe a PLR. We plan to compare these subjective opinions with objective findings from pupillometry.
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Menozzi M, Gosse J, Talamonti M, Di Bernardini E, Quispe Cornejo A, Gustot T, Creteur J, Peluso L, Taccone FS. The use of automated pupillometry in critically ill cirrhotic patients with hepatic encephalopathy. J Crit Care 2020; 62:176-182. [PMID: 33388562 DOI: 10.1016/j.jcrc.2020.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE To evaluate whether pupillary abnormalities would correlate with the severity of encephalopathy in critically ill cirrhotic patients. METHODS In this retrospective study, we enrolled adult cirrhotic patients admitted to the Intensive Care Unit undergoing automated pupillometry assessment within the first 72 h since ICU admission. Encephalopathy was assessed with West-Haven classification and Glasgow Coma Scale. Pupillometry-derived variables were also correlated with biological variables, including ammonium, renal function or inflammatory parameters, measured on the day of pupillary assessment. RESULTS A total of 62 critically ill cirrhotic patients (Age 61 [52-68] years; 69% male) were included. Median GCS and West-Haven classification were 14 [11-15] and 1 [0-3], respectively. There was a significant although weak correlation between GCS and constriction velocity (CV; R2 = 0.1; p = 0.017). We observed significant differences in CV and DV values among different levels of West-Haven classification. When only patients with encephalopathy (n = 42) or severe HE (n = 18) were considered, a weak correlation between GCS and worst CV was observed. When patients receiving sedatives or opioids were excluded, no significant correlation between pupillometry and clinical variables was observed. CONCLUSIONS Pupillary function assessed by the automated pupillometry was poorly associated with encephalopathy scales in cirrhotic patients.
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Affiliation(s)
- Marco Menozzi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Juliette Gosse
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marta Talamonti
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Eugenio Di Bernardini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Armin Quispe Cornejo
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Thierry Gustot
- Liver Transplant Unit, Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium.
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Automated Pupillary Measurements Inversely Correlate With Increased Intracranial Pressure in Pediatric Patients With Acute Brain Injury or Encephalopathy. Pediatr Crit Care Med 2020; 21:753-759. [PMID: 32195898 DOI: 10.1097/pcc.0000000000002327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to determine correlation and temporal association between automated pupillary measurements and intracranial pressure in pediatric patients with brain injury or encephalopathy requiring intracranial pressure monitoring. We hypothesized that abnormal pupillary measurements would precede increases in intracranial pressure. DESIGN A prospective cohort study was performed. Automated pupillometry measurements were obtained at the same frequency as the patients' neurologic assessments with concurrent measurement of intracranial pressure, for up to 72 hours. Pupillary measurements and the Neurologic Pupil index, an algorithmic score that combines measures of pupillary reactivity, were assessed for correlation with concurrent and future intracranial pressure measurements. SETTING Single-center pediatric quaternary ICU, from July 2017 to October 2018. PATIENTS Pediatric patients 18 years or younger with a diagnosis of acute brain injury or encephalopathy requiring an intracranial pressure monitor. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty-eight patients were analyzed with a total of 1,171 intracranial pressure measurements. When intracranial pressure was elevated, the Neurologic Pupil index, percent change in pupillary size, constriction velocity, and dilation velocity were significantly lower than when intracranial pressure was within normal range (p < 0.001 for all). There were mild to moderate negative correlations between concurrent intracranial pressure and pupillary measurements. However, there was an inconsistent pattern of abnormal pupillary measurements preceding increases in intracranial pressure; some patients had a negative association, while others had a positive relationship or no relationship between Neurologic Pupil index and intracranial pressure. CONCLUSIONS Our data indicate automated assessments of pupillary reactivity inversely correlate with intracranial pressure, demonstrating that pupillary reactivity decreases as intracranial pressure increases. However, a temporal association in which abnormal pupillary measurements precede increases in intracranial pressure was not consistently observed. This work contributes to limited data available regarding automated pupillometry in neurocritically ill patients, and the even more restricted subset available in pediatrics.
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Phillips SS, Mueller CM, Nogueira RG, Khalifa YM. A Systematic Review Assessing the Current State of Automated Pupillometry in the NeuroICU. Neurocrit Care 2020; 31:142-161. [PMID: 30484008 DOI: 10.1007/s12028-018-0645-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of this study was to assess the current state of automated pupillometry technology and its application in the neurointensive care unit (neuroICU). We performed a literature search using the PubMed, MEDLINE, and EMBASE databases from database inception through a search end date of October 18, 2018, to identify studies reporting on the use of automated pupillometry in the care of critically ill patients with neurological impairment. Two independent reviewers reviewed all titles and abstracts in two filtering phases. Data were extracted independently. One hundred and forty-one articles/abstracts have been published on the use of automated pupillometry in critical care since inception of the PubMed, MEDLINE, and EMBASE databases. We selected and reviewed 22 full-text articles and 8 abstracts, of which 26 were prospective, 2 were retrospective, and 2 were larger case series. Automated pupillometry increased precision, reliability, and reproducibility compared with the manual pupillary examination; detected subtle and early pupillary changes; detected pupillary changes that indicate a rise, or impending rise, in intracranial pressure detected level of analgesia and depth of sedation; served as a prognostic indicator; estimated the clinical severity of aneurysmal subarachnoid hemorrhage; and served as a noninvasive monitor of response to osmotic therapy. At present, no consensus guidelines exist endorsing routine use of automated pupillometry in the neuroICU. However, an increasing quantity of research supports the usefulness of automated pupillometry in this setting. Further large-scale prospective studies are needed before updated consensus guidelines recommending widespread adoption of automated pupillometry are produced.
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Affiliation(s)
| | | | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Yousuf M Khalifa
- Department of Ophthalmology, Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA.
- Department of Ophthalmology, Grady Memorial Hospital, Atlanta, GA, USA.
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Smith J, Flower O, Tracey A, Johnson P. A comparison of manual pupil examination versus an automated pupillometer in a specialised neurosciences intensive care unit. Aust Crit Care 2020; 33:162-166. [DOI: 10.1016/j.aucc.2019.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/17/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022] Open
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Comparison of 2 Automated Pupillometry Devices in Critically III Patients. J Neurosurg Anesthesiol 2019; 32:323-329. [DOI: 10.1097/ana.0000000000000604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Brain and the Liver: Cerebral Edema, Hepatic Encephalopathy and Beyond. HEPATIC CRITICAL CARE 2018. [PMCID: PMC7122599 DOI: 10.1007/978-3-319-66432-3_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Occurrence of brain dysfunction is common in both chronic liver disease as well as acute liver failure. While brain dysfunction most commonly manifests as hepatic encephalopathy is chronic liver disease; devastating complications of cerebral edema and brain herniation syndromes may occur with acute liver failure. Ammonia seems to play a central role in the pathogenesis of brain dysfunction in both chronic liver disease and acute liver failure. In this chapter we outline the pathophysiology and clinical management of brain dysfunction in the critically ill patients with liver disease.
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Abstract
Hepatic encephalopathy occurs ubiquitously in all causes of advanced liver failure, however, its implications on mortality diverge and vary depending upon acuity and severity of liver failure. This associated mortality has decreased in subsets of liver failure over the last 20 years. Aside from liver transplantation, this improvement is not attributable to a single intervention but likely to a combination of practical advances in critical care management. Misconceptions surrounding many facets of hepatic encephalopathy exists due to heterogeneity in presentation, pathophysiology and outcome. This review is intended to highlight the important concepts, rationales and strategies for managing hepatic encephalopathy.
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Affiliation(s)
- Prem A Kandiah
- Division of Neuro Critical Care, Department of Neurosurgery, Co-appointment in Surgical Critical Care, Emory University Hospital, 1364 Clifton Road Northeast, 2nd Floor, 2D ICU-D264, Atlanta, GA 30322, USA.
| | - Gagan Kumar
- Department of Critical Care, Phoebe Putney Memorial Hospital, 417 Third Avenue, Albany, GA 31701, USA
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Couret D, Boumaza D, Grisotto C, Triglia T, Pellegrini L, Ocquidant P, Bruder NJ, Velly LJ. Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:99. [PMID: 27072310 PMCID: PMC4828754 DOI: 10.1186/s13054-016-1239-z] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/17/2016] [Indexed: 11/10/2022]
Abstract
Background In critical care units, pupil examination is an important clinical parameter for patient monitoring. Current practice is to use a penlight to observe the pupillary light reflex. The result seems to be a subjective measurement, with low precision and reproducibility. Several quantitative pupillometer devices are now available, although their use is primarily restricted to the research setting. To assess whether adoption of these technologies would benefit the clinic, we compared automated quantitative pupillometry with the standard clinical pupillary examination currently used for brain-injured patients. Methods In order to determine inter-observer agreement of the device, we performed repetitive measurements in 200 healthy volunteers ranging in age from 21 to 58 years, providing a total of 400 paired (alternative right eye, left eye) measurements under a wide variety of ambient light condition with NeuroLight Algiscan pupillometer. During another period, we conducted a prospective, observational, double-blinded study in two neurocritical care units. Patients admitted to these units after an acute brain injury were included. Initially, nursing staff measured pupil size, anisocoria and pupillary light reflex. A blinded physician subsequently performed measurement using an automated pupillometer. Results In 200 healthy volunteers, intra-class correlation coefficient for maximum resting pupil size was 0.95 (IC: 0.93-0.97) and for minimum pupil size after light stimulation 0.87 (0.83–0.89). We found only 3-pupil asymmetry (≥1 mm) in these volunteers (1.5 % of the population) with a clear pupil asymmetry during clinical inspection. The mean pupil light reactivity was 40 ± 7 %. In 59 patients, 406 pupillary measurements were prospectively performed. Concordance between measurements for pupil size collected using the pupillometer, versus subjective assessment, was poor (Spearmen's rho = 0.75, IC: 0.70-0.79; P < 0.001). Nursing staff failed to diagnose half of the cases (15/30) of anisocoria detected using the pupillometer device. A global rate of discordance of 18 % (72/406) was found between the two techniques when assessing the pupillary light reflex. For measurements with small pupils (diameters <2 mm) the error rate was 39 % (24/61). Conclusion Standard practice in pupillary monitoring yields inaccurate data. Automated quantitative pupillometry is a more reliable method with which to collect pupillary measurements at the bedside. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1239-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Couret
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion University, BP 350, Saint Pierre, 97448, la Réunion, France.,Inserm, UMR 1188 Diabète athérothrombose Thérapies Réunion Océan Indien (DéTROI), plateforme CYROI, 2 rue Maxime Rivière, Sainte Clotilde, 97490, la Réunion, France
| | - Delphine Boumaza
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Coline Grisotto
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion University, BP 350, Saint Pierre, 97448, la Réunion, France
| | - Thibaut Triglia
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Lionel Pellegrini
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Philippe Ocquidant
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion University, BP 350, Saint Pierre, 97448, la Réunion, France
| | - Nicolas J Bruder
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Lionel J Velly
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France.
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Shirozu K, Setoguchi H, Tokuda K, Karashima Y, Ikeda M, Kubo M, Nakamura K, Hoka S. The effects of anesthetic agents on pupillary function during general anesthesia using the automated infrared quantitative pupillometer. J Clin Monit Comput 2016; 31:291-296. [PMID: 26858211 DOI: 10.1007/s10877-016-9839-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 02/03/2016] [Indexed: 11/25/2022]
Abstract
Pupil reactivity can be used to evaluate central nervous system function and can be measured using a quantitative pupillometer. However, whether anesthetic agents affect the accuracy of the technique remains unclear. We examined the effects of anesthetic agents on pupillary reactivity. Thirty-five patients scheduled for breast or thyroid surgery were enrolled in the study. Patients were divided into four groups based on the technique used to maintain anesthesia: a sevoflurane-remifentanil (SEV/REM) group, a sevoflurane (SEV) group, a desflurane-remifentanil (DES/REM) group, and a propofol-remifentanil (PRO/REM) group. We measured maximum resting pupil size (MAX), reduction pupil size ratio (%CH), latency duration (LAT) and neurological pupil index (NPi). A marked reduction in MAX and %CH compared with baseline was observed in all groups, but LAT was unchanged during surgery. NPi reduced within the first hour of surgery in the SEV/REM, SEV, and DES/REM groups, but was not significantly different in the PRO/REM group. Compared with the PRO/REM group, mean %CH and NPi in patients anesthetized with SEV/REM, SEV or DES/REM were markedly lower at 1 h after surgery had commenced. There was no correlation between NPi and bispectral index. Fentanyl given alone decreased pupil size and %CH in light reflex, but did not change the NPi. NPi was decreased by inhalational anesthesia not but intravenous anesthesia. The difference in pupil reactivity between inhalational anesthetic and propofol may indicate differences in the alteration of midbrain reflexs in patients under inhalational or intravenous anesthesia.
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Affiliation(s)
- Kazuhiro Shirozu
- Operating Rooms, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Hidekazu Setoguchi
- Operating Rooms, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kentaro Tokuda
- Intensive Care Unit, Kyushu University Hospital, Fukuoka, Japan
| | - Yuji Karashima
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mizuko Ikeda
- Operating Rooms, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Makoto Kubo
- Department of Surgery and Oncology, Kyushu University Hospital, Fukuoka, Japan
| | - Katsuya Nakamura
- Department of Surgery and Oncology, Kyushu University Hospital, Fukuoka, Japan
| | - Sumio Hoka
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Shi Y, Yan H, Zhou Z, Fang H, Li J, Ye H, Sun W, Zhou W, Ye J, Yang Q, Yang Y, Hu Y, Chen Z, Sheng J. The Clinical Course of Cirrhosis Patients Hospitalized for Acute Hepatic Deterioration: A Prospective Bicentric Study. Medicine (Baltimore) 2015; 94:e2031. [PMID: 26632701 PMCID: PMC5058970 DOI: 10.1097/md.0000000000002031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Patients with cirrhosis are vulnerable to acute hepatic insults and are more likely to develop rapid hepatic deterioration. The aim of this study is to describe the clinical course of patients with cirrhosis and hospitalized for acute hepatic deterioration (AHD).This is a prospective study involving 163 patients with cirrhosis and AHD. The occurrence of organ failures, systemic inflammatory response syndrome (SIRS), and infections during hospital stay were recorded and the relationship between organ failure and death or SIRS/infection was subsequently analyzed.Of 163 patients, 35 did not develop any organ failure during in-hospital follow-ups (90-day mortality: 0%); 84 had intrahepatic organ failures (IH-OFs, defined by liver and/or coagulation failure) (90-day mortality: 22.0%); and 44 patients developed extra-hepatic organ failures (EH-OFs, defined by kidney, cerebral, circulation, and respiratory failure) on the basis of IH-OF with a 90-day mortality of 90.9%. On multivariable analysis by a Cox proportion hazard model, age, WBC, presence of IH-OF, and EH-OF all predicted 90-day death. A logistic regression analysis identified SIRS being associated with the development of EH-OF. Furthermore, IH-OF at admission and infections occurred during the hospital stay were shown to be another 2 potential risk factors.The clinical course of cirrhosis patients with acute hepatic injury was characterized by 3 consecutive stages (AHD, IH-OF, and EH-OF), which provided a clear risk stratification. The PIRO criteria provided an accurate frame for prognostication of those patients. The systemic inflammatory response syndrome may be a target for blocking the progression to the EH-OF stage.
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Affiliation(s)
- Yu Shi
- From the State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China (YS, ZZ, HF, YY, ZC, JS); Department of Infectious Diseases, Ningbo Multiple Organ Injury Research Center, Ningbo No. 2 Hospital, School of Medicine, Ningbo University, Ningbo, China (HY, WZ, JY, YH); Department of Cardiology, Ningbo Multiple Organ Injury Research Center, Ningbo No. 2 Hospital, School of Medicine, Ningbo University, Ningbo, China (HY); Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China (WS); Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China (QY); and Center for Hepatology, University College London, London, United Kingdom (JL)
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Park JG, Moon CT, Park DS, Song SW. Clinical Utility of an Automated Pupillometer in Patients with Acute Brain Lesion. J Korean Neurosurg Soc 2015; 58:363-7. [PMID: 26587191 PMCID: PMC4651998 DOI: 10.3340/jkns.2015.58.4.363] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 11/27/2022] Open
Abstract
Objective The purpose of this study was to evaluate the clinical utility and validity of using a pupillometer to assess patients with acute brain lesions. Methods Pupillary examinations using an automated pupillometer (NeurOptics®NPi™-100 Pupillometer) were performed every 4 hours and were simultaneously assessed using the Glasgow Coma Scale (GCS) and for intracranial pressure (ICP), from admission to discharge or expire in neuro-intensive care unit (NICU). Manual pupillary examinations were also recorded for comparison. By comparing these data, we evaluated the validity of using automated pupillometers to predict clinical outcomes. Results The mean values of the Neurologic Pupillary index (NPi) were different in the groups examined manually. The GCS correlated well with NPi values, especially in severe brain injury patients (GCS below 9). However, the NPi values were weakly correlated with intracranial pressure (ICP) when the ICP was lower than 30 cm H2O. The NPi value was not affected by age or intensity of illumination. In patients with a "poor" prognosis who had a Glasgow Outcome Scale (GOS) of 1 or 2, the mean initial NPi score was 0.88±1.68, whereas the value was 3.89±0.97 in patients with a "favorable" prognosis who had a GOS greater than 2 (p<0.001). For predicting clinical outcomes, the initial NPi value of 3.4 had the highest sensitivity and specificity. Conclusion An automated pupillometer can serve as a simple and useful tool for the accurate measurement of pupillary reactivity in patients with acute brain lesions.
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Affiliation(s)
- Jeong Goo Park
- Department of Neurosurgery, Konkuk University Medical Center, Seoul, Korea
| | - Chang Taek Moon
- Department of Neurosurgery, Konkuk University Medical Center, Seoul, Korea
| | - Dong Sun Park
- Department of Neurosurgery, Konkuk University Medical Center, Seoul, Korea
| | - Sang Woo Song
- Department of Neurosurgery, Konkuk University Medical Center, Seoul, Korea
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Suys T, Bouzat P, Marques-Vidal P, Sala N, Payen JF, Rossetti AO, Oddo M. Automated quantitative pupillometry for the prognostication of coma after cardiac arrest. Neurocrit Care 2015; 21:300-8. [PMID: 24760270 DOI: 10.1007/s12028-014-9981-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sedation and therapeutic hypothermia (TH) delay neurological responses and might reduce the accuracy of clinical examination to predict outcome after cardiac arrest (CA). We examined the accuracy of quantitative pupillary light reactivity (PLR), using an automated infrared pupillometry, to predict outcome of post-CA coma in comparison to standard PLR, EEG, and somato-sensory evoked potentials (SSEP). METHODS We prospectively studied over a 1-year period (June 2012-June 2013) 50 consecutive comatose CA patients treated with TH (33 °C, 24 h). Quantitative PLR (expressed as the % of pupillary response to a calibrated light stimulus) and standard PLR were measured at day 1 (TH and sedation; on average 16 h after CA) and day 2 (normothermia, off sedation: on average 46 h after CA). Neurological outcome was assessed at 90 days with Cerebral Performance Categories (CPC), dichotomized as good (CPC 1-2) versus poor (CPC 3-5). Predictive performance was analyzed using area under the ROC curves (AUC). RESULTS Patients with good outcome [n = 23 (46 %)] had higher quantitative PLR than those with poor outcome [n = 27; 16 (range 9-23) vs. 10 (1-30) % at day 1, and 20 (13-39) vs. 11 (1-55) % at day 2, both p < 0.001]. Best cut-off for outcome prediction of quantitative PLR was <13 %. The AUC to predict poor outcome was higher for quantitative than for standard PLR at both time points (day 1, 0.79 vs. 0.56, p = 0.005; day 2, 0.81 vs. 0.64, p = 0.006). Prognostic accuracy of quantitative PLR was comparable to that of EEG and SSEP (0.81 vs. 0.80 and 0.73, respectively, both p > 0.20). CONCLUSIONS Quantitative PLR is more accurate than standard PLR in predicting outcome of post-anoxic coma, irrespective of temperature and sedation, and has comparable prognostic accuracy than EEG and SSEP.
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Affiliation(s)
- Tamarah Suys
- Neuroscience Critical Care Research Group, Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University Hospital and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
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Kim KM, Kim GS, Ko JS, Gwak MS, Lee SK, Son MG. Factors associated with consciousness recovery time after liver transplantation in recipients with hepatic encephalopathy. Transplant Proc 2015; 46:712-5. [PMID: 24767331 DOI: 10.1016/j.transproceed.2013.12.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 11/30/2013] [Accepted: 12/11/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) occurs as a result of liver failure and is often considered to be a clinical indication for liver transplantation (LT). An assessment of post-transplantation consciousness level in recipients with HE is crucial, because recovery of consciousness implies reestablishment of transplant liver function and lack of perioperative brain damage. The purpose of this study is to evaluate factors associated with consciousness recovery time after LT in recipients with HE. METHODS Out of 633 adult recipients who underwent LT, recipients who exhibited HE at the time of LT were analyzed retrospectively. The time between graft reperfusion and postoperative consciousness recovery was determined, and recipients were divided into 2 groups: group E with recovery of consciousness early (≤48 hours), and group L with recovery of consciousness late (>48 hours). Analyzed variables included recipient sex, age, graft type, Model for End-Stage Liver Disease score, HE history/duration/type/grade, and preoperative laboratory values, including blood ammonia concentration. RESULTS HE was present at the time of LT in 69 (10.9%) of 633 recipients. Among the 69 recipients, 11 recipients who died or underwent reoperation before consciousness recovery were excluded, and 58 recipients (group E: n = 32; group L: n = 26) were enrolled into analysis. Multivariate analysis showed that HE duration >5 days (odds ratio [OR], 15.58; 95% confidence interval [CI], 1.35-179.56; P = .028) and HE type C (OR, 30.90; 95% CI, 1.67-573.48; P = .021) were the independent factors associated with late recovery from HE after LT. CONCLUSIONS We suggest that recipients with long-duration or type C HE should be carefully managed during the post-transplantation period to prevent deterioration of HE.
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Affiliation(s)
- K M Kim
- Department of Anesthesiology and Pain Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Hwasung, Korea
| | - G S Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - J S Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - M S Gwak
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - S-K Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - M G Son
- Department of Anesthesiology and Pain Medicine, Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Hwasung, Korea
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Automated pupillometer for monitoring the critically ill patient: A critical appraisal. J Crit Care 2014; 29:599-603. [DOI: 10.1016/j.jcrc.2014.01.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/02/2014] [Accepted: 01/19/2014] [Indexed: 01/29/2023]
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Roberts DK, Yang Y, Lukic AS, Wilensky JT, Wernick MN. Quantification of Pupil Parameters in Diseased and Normal Eyes With Near Infrared Iris Transillumination Imaging. Ophthalmic Surg Lasers Imaging Retina 2012; 43:196-204. [DOI: 10.3928/15428877-20120301-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 01/13/2012] [Indexed: 12/28/2022]
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