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Zhou Y, He X, Liu Z, Xu L, Li L, Chen J, Zhao J, Li R, Yan C, Yu C, Yu F, He W, Qin G, Yu S. Agreement and repeatability of scotopic pupil size measurement with the 2WIN-S portable refractor in Chinese adults. Sci Rep 2024; 14:15650. [PMID: 38977905 PMCID: PMC11231274 DOI: 10.1038/s41598-024-66540-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 07/02/2024] [Indexed: 07/10/2024] Open
Abstract
To assess the agreement and repeatability of scotopic pupil size measurement using 2WIN-S (Adaptica, Padova, Italy) portable refractor in Chinese adults. This prospective non-randomized open-label controlled study assessed the scotopic pupil size of 100 right eyes using OPD-Scan III (Optical path difference) (Nidek Technologies, Gamagori, Japan) and 2WIN-S. OPD-Scan III and 2WIN-S measure pupil size using infrared light and detector, while 2WIN-S measures bilateral eyes simultaneously, OPD-Scan III measures unilateral eyes individually. Participants were first measured once using OPD-Scan III and two consecutive measurements were performed using 2WIN-S after 15 min of rest interval. The primary outcome was to evaluate the agreement between 2WIN-S and OPD-Scan III, and the secondary outcome was to evaluate the repeatability of 2WIN-S. Scotopic pupil size of 100 right eyes of 100 adults (28 male and 72 female) aged 18-53 years (mean 36 ± 12 years) was assessed using OPD-Scan III and 2WIN-S, respectively. The mean scotopic pupil size of OPD-Scan III and 2WIN-S was recorded to be 6.24 ± 0.88 mm and 6.27 ± 0.81 mm, respectively. For the mean scotopic pupil size of OPD-Scan III and 2WIN-S the difference was - 0.03 mm (95%CI - 0.10 to 0.04 mm), p = 0.445, the 95% limits of agreement (LOA) was - 0.71 to 0.66 mm. ICC between the two devices was 0.92 (95% CI 0.88-0.94) (ICC > 0.9 indicates excellent consistency). Coefficients of repeatability (CoR) of 2WIN-S was 0.37, which has a high repeatability. For the mean scotopic pupil size of 2WIN-S of the repeated measurements, the difference was -0.04 mm (95%CI - 0.08 to 0.01 mm), p = 0.019, the 95% limits of agreement (LOA) was - 0.41 to 0.32 mm, with a narrow LOA. However, the majority of the variations were less than ± 0.50 mm (98% of scotopic pupil size measurements were below this threshold), within the clinically acceptable range (± 0.50 mm). Our study showed excellent agreement between 2WIN-S and OPD-Scan III (ICC > 0.9) and a good repeatability of 2WIN-S (CoR = 0.37). This study suggests a novel technique for measuring pupillary responses in low light conditions, which can be considered an alternative to OPD-Scan III in clinical settings.
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Affiliation(s)
- Yibing Zhou
- School of Public Health, Dalian Medical University, Dalian, China
- Department of Clinical Research, He Eye Specialist Hospital, Shenyang, China
| | - Xingru He
- School of Public Health, He University, Shenyang, China
| | - Ziming Liu
- School of Public Health, He University, Shenyang, China
| | - Ling Xu
- Department of Clinical Research, He Eye Specialist Hospital, Shenyang, China
| | - Liangzhe Li
- Department of Clinical Research, He Eye Specialist Hospital, Shenyang, China
| | - Jiayan Chen
- Department of Clinical Research, He Eye Specialist Hospital, Shenyang, China
| | - Jiahui Zhao
- Department of Clinical Research, He Eye Specialist Hospital, Shenyang, China
| | - Ruyi Li
- School of Public Health, Dalian Medical University, Dalian, China
- Department of Clinical Research, He Eye Specialist Hospital, Shenyang, China
| | - Chunhong Yan
- School of Public Health, He University, Shenyang, China
| | - Cui Yu
- School of Optometry, He University, Shenyang, China
| | - Fei Yu
- School of Public Health, He University, Shenyang, China
| | - Wei He
- Department of Clinical Research, He Eye Specialist Hospital, Shenyang, China
| | - Guanghao Qin
- Department of Clinical Research, He Eye Specialist Hospital, Shenyang, China.
| | - Sile Yu
- Department of Clinical Research, He Eye Specialist Hospital, Shenyang, China.
- School of Public Health, He University, Shenyang, China.
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Casas-Alvarado A, Martínez-Burnes J, Hernández-Ávalos I, Mora-Medina P, Miranda-Cortés A, Domínguez-Oliva A, Mota-Rojas D. Assessment of the nociceptive response to the use of cannabidiol alone and in combination with meloxicam through infrared pupillometry in female dogs undergoing elective ovariohysterectomy. Front Vet Sci 2024; 11:1380022. [PMID: 39027908 PMCID: PMC11256235 DOI: 10.3389/fvets.2024.1380022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/17/2024] [Indexed: 07/20/2024] Open
Abstract
The negative effects of pain are a constant concern in the surgical management of animals, leading to the search for new drugs or more effective analgesic protocols to control this negative emotion. This study aimed to evaluate the nociceptive response of cannabidiol (CBD) alone and in combination with meloxicam using infrared pupillometry in female dogs undergoing elective ovariohysterectomy (OVH) under isoflurane anesthesia. A total of 60 female dogs of different breeds were included. These dogs were randomly assigned to four study groups according to the treatment: Control Group (G0: n = 15) receiving saline solution; group premedicated with meloxicam at a dose of 0.2 mg Kg-1 IV (GMelox: n = 15). Postoperatively this drug was used at 0.1 mg Kg-1 IV every 24 h; the CBD-treated Group (GCBD: n = 15) at a dose of 2 mg Kg-1 orally in the preoperative. Postoperatively was administrated every 12 h; and the Group premedicated with the combination of meloxicam and CBD (GMelox/CBD: n = 15) Meloxicam at a dose of 0.2 mg Kg-1 IV preoperatively, and 0.1 mg Kg-1 IV during the postoperative. CBD at a dose of 2 mg Kg-1 orally in the preoperative, and every 12 h in the postoperative. Treatments were administered for 48 postoperative hours. After OVH, the pupillary neurologic index, pupillary size, minimum diameter (MIN), percentage change, constriction latency (Lat), constriction velocity, and maximum constriction velocity were recorded as pupillometric variables in both eyes during events (E): Baseline (30 min before drug administration), E30 min, E1h, E2h, E3h, E4h, E8h, E12h, E24h, and E48h. The Short-Form of the Glasgow Composite Measure Pain Scale (GCMPS-SF) was used to assess pain during the same events. Overall, it was observed that the pupillometric variables Size, MIN., and Lat. were significantly higher in G0 compared to the other groups during E30 min, E1h, and E2h (p = 0.03), indicating greater pupil dilation in G0 animals. Additionally, no statistically significant differences were observed in GCMPS-SF between GMelox, GCBD, and GMelox/CBD during the postoperative period (p > 0.05). In contrast, the scores were statistically different compared to G0 (p = 0.00001), where all animals in this group received rescue analgesia at 2 h post-surgery. According to pupillometry and scores on the GCMPS-SF scale, it was observed that monotherapy with cannabidiol provides a similar analgesic effect to meloxicam alone or in combination with cannabidiol to manage acute pain in dogs. Similarly, these findings suggest that infrared pupillometry could be a tool for recognizing acute pain in dogs.
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Affiliation(s)
- Alejandro Casas-Alvarado
- Doctorado en Ciencias Biológicas y de la Salud, Universidad Autónoma Metropolitana, Mexico City, Mexico
| | - Julio Martínez-Burnes
- Facultad de Medicina Veterinaria y Zootecnia, Universidad Autónoma de Tamaulipas, Ciudad Victoria, Mexico
| | - Ismael Hernández-Ávalos
- Clinical Pharmacology and Veterinary Anesthesia, Biological Sciences Department, FESC, Universidad Nacional Autónoma de México, Cuautitlán, Mexico
| | - Patricia Mora-Medina
- Facultad de Estudios Superiores Cuautitlán, Universidad Nacional Autónoma de México, Cuautitlán Izcalli, Mexico
| | - Agatha Miranda-Cortés
- Clinical Pharmacology and Veterinary Anesthesia, Biological Sciences Department, FESC, Universidad Nacional Autónoma de México, Cuautitlán, Mexico
| | - Adriana Domínguez-Oliva
- Neurophysiology of Pain, Behavior and Assessment of Welfare in Domestic Animals, DPAA, Universidad Autónoma Metropolitana, Mexico City, Mexico
| | - Daniel Mota-Rojas
- Neurophysiology of Pain, Behavior and Assessment of Welfare in Domestic Animals, DPAA, Universidad Autónoma Metropolitana, Mexico City, Mexico
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Philibert M, Milea D. Basics, benefits, and pitfalls of pupillometers assessing visual function. Eye (Lond) 2024:10.1038/s41433-024-03151-9. [PMID: 38802485 DOI: 10.1038/s41433-024-03151-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/22/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024] Open
Abstract
Numerous commercially and non-commercially available pupillometers are nowadays able to assess various biological functions in humans, by evaluating pupils' dynamics in response to specific stimuli. However, the use of pupillometers for ophthalmic afferent evaluations (i.e., photoreceptoral responses) in real-world settings is relatively limited. Recent scientific and technological advances, coupled with artificial intelligence methods have improved the performance of such devices to objectively detect, quantify, and classify functional disturbances of the retina and the optic nerve. This review aims to summarize the scientific principles, indications, outcomes, and current limitations of pupillometry used for evaluation of afferent pathways in ophthalmic clinical settings.
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Affiliation(s)
| | - Dan Milea
- Rothschild Foundation Hospital, Paris, France.
- Copenhagen University Hospital, Copenhagen, Denmark.
- Singapore National Eye Centre, Singapore, Singapore.
- Angers University Hospital, Angers, France.
- Duke-NUS Medical School, Singapore, Singapore.
- Singapore Eye Research Institute, Singapore, Singapore.
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Figueroa SA, Olson DM, Kamal A, Aiyagari V. Quantitative Pupillometry: Clinical Applications for the Internist. Am J Med 2024:S0002-9343(24)00283-3. [PMID: 38734045 DOI: 10.1016/j.amjmed.2024.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024]
Abstract
From the time of Galen, examination of the pupillary light reflex has been a standard of care across the continuum of health care. The growing body of evidence overwhelmingly supports the use of quantitative pupillometry over subjective examination with flashlight or penlight. At current time, pupillometers have become standard of care in many hospitals across 6 continents. This review paper provides an overview and rationale for pupillometer use and highlights literature supporting pupillometer-derived measures of the pupillary light reflex in both neurological and non-neurological patients across the health care continuum.
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Affiliation(s)
- Stephen A Figueroa
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas; Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas; Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas.
| | - DaiWai M Olson
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas; Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas; Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas
| | - Abdulkadir Kamal
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas; Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas; Department of Nursing, University of Texas Southwestern Medical Center, Dallas
| | - Venkatesh Aiyagari
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas; Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas; Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center, Dallas
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Behrends M, Larson MD. Measurements of pupillary unrest using infrared pupillometry fail to detect changes in pain intensity in patients after surgery: a prospective observational study. Can J Anaesth 2024; 71:611-618. [PMID: 38504035 PMCID: PMC11026258 DOI: 10.1007/s12630-024-02716-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/14/2023] [Accepted: 11/21/2023] [Indexed: 03/21/2024] Open
Abstract
PURPOSE The pupil displays chaotic oscillations, also referred to as pupillary unrest in ambient light (PUAL). As pain has previously been shown to increase pupillary unrest, the quantitative assessment of PUAL has been considered a possible tool to identify and quantify pain. Nevertheless, PUAL is affected by various states, such as vigilance, cognitive load, or emotional arousal, independent of pain. Furthermore, systematically applied opioids are known to reduce PUAL, thus potentially limiting its usefulness to detect pain or changes in pain intensity. To test the hypothesis that PUAL can reliably identify changes in pain intensity in a clinical setting, we measured PUAL in patients experiencing substantial pain relief when regional anesthesia interventions were applied after surgery. METHODS We conducted an observational study at an academic surgery centre following institutional review board approval. Eighteen patients with unsatisfactory pain control following surgery underwent regional anesthesia procedures to improve pain control. We used infrared pupillometry to assess pupillary unrest before and after the regional block. We then compared the changes in pupillary unrest with the changes in pain scores (numeric rating scale [NRS], range 0-10). RESULTS Eighteen patients received epidural anesthesia (n = 14) or peripheral nerve blocks (n = 4), resulting in improvement of mean (standard deviation [SD]) NRS pain scores from 7.2 (1.7) to 1.9 (1.8) (difference in means, -2.2; 95% confidence interval [CI], -6.3 to -4.1; P < 0.001). Nevertheless, pupillary unrest did not change as pain decreased; the mean (SD) PUAL was 0.113 (0.062) before analgesia and 0.112 (0.068) after analgesia (difference in means, -0.001; 95% CI, -0.018 to 0.015; P = 0.88). CONCLUSION In this prospective observational study, pupillometric measurements of pupillary unrest did not identify changes in pain intensity in a postoperative, predominantly opioid-exposed patient population. While the sample size was small, the use of measurements of pupillary unrest to detect and quantify pain has to be questioned.
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Affiliation(s)
- Matthias Behrends
- Department of Anesthesia and Perioperative Care, University of California, 521 Parnassus Avenue, #4307, San Francisco, CA, 94117, USA.
| | - Merlin D Larson
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
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Bogucki A, John I, Zinkiewicz Ł, Jachura M, Jaworski D, Suwała K, Chrost H, Wlodarski M, Kałużny J, Campbell D, Bakken P, Pandya S, Chrapkiewicz R, Manohar SG. Machine learning approach for ambient-light-corrected parameters and the Pupil Reactivity (PuRe) score in smartphone-based pupillometry. Front Neurol 2024; 15:1363190. [PMID: 38654735 PMCID: PMC11037402 DOI: 10.3389/fneur.2024.1363190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/18/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction The pupillary light reflex (PLR) is the constriction of the pupil in response to light. The PLR in response to a pulse of light follows a complex waveform that can be characterized by several parameters. It is a sensitive marker of acute neurological deterioration, but is also sensitive to the background illumination in the environment in which it is measured. To detect a pathological change in the PLR, it is therefore necessary to separate the contributions of neuro-ophthalmic factors from ambient illumination. Illumination varies over several orders of magnitude and is difficult to control due to diurnal, seasonal, and location variations. Methods and results We assessed the sensitivity of seven PLR parameters to differences in ambient light, using a smartphone-based pupillometer (AI Pupillometer, Solvemed Inc.). Nine subjects underwent 345 measurements in ambient conditions ranging from complete darkness (<5 lx) to bright lighting (≲10,000 lx). Lighting most strongly affected the initial pupil size, constriction amplitude, and velocity. Nonlinear models were fitted to find the correction function that maximally stabilized PLR parameters across different ambient light levels. Next, we demonstrated that the lighting-corrected parameters still discriminated reactive from unreactive pupils. Ten patients underwent PLR testing in an ophthalmology outpatient clinic setting following the administration of tropicamide eye drops, which rendered the pupils unreactive. The parameters corrected for lighting were combined as predictors in a machine learning model to produce a scalar value, the Pupil Reactivity (PuRe) score, which quantifies Pupil Reactivity on a scale 0-5 (0, non-reactive pupil; 0-3, abnormal/"sluggish" response; 3-5, normal/brisk response). The score discriminated unreactive pupils with 100% accuracy and was stable under changes in ambient illumination across four orders of magnitude. Discussion This is the first time that a correction method has been proposed to effectively mitigate the confounding influence of ambient light on PLR measurements, which could improve the reliability of pupillometric parameters both in pre-hospital and inpatient care settings. In particular, the PuRe score offers a robust measure of Pupil Reactivity directly applicable to clinical practice. Importantly, the formulae behind the score are openly available for the benefit of the clinical research community.
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Affiliation(s)
| | - Ivo John
- Solvemed Inc., Lewes, DE, United States
| | | | | | - Damian Jaworski
- Oftalmika Eye Hospital, Bydgoszcz, Poland
- Division of Ophthalmology and Optometry, Department of Ophthalmology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Karolina Suwała
- Oftalmika Eye Hospital, Bydgoszcz, Poland
- Department of Sensory Organ Studies, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | | | - Jakub Kałużny
- Oftalmika Eye Hospital, Bydgoszcz, Poland
- Department of Sensory Organ Studies, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Doug Campbell
- Space Medicine Group, International Institute for Astronautical Sciences, Boulder, CO, United States
| | - Paul Bakken
- Space Medicine Group, International Institute for Astronautical Sciences, Boulder, CO, United States
| | - Shawna Pandya
- Space Medicine Group, International Institute for Astronautical Sciences, Boulder, CO, United States
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Konno M, Niwa H, Kitayama M, Hirota K. Video versus ultrasound pupillometry for detecting increased pupillary diameters due to nociceptive stimuli: a prospective observational study. J Anesth 2024; 38:191-197. [PMID: 38189944 DOI: 10.1007/s00540-023-03297-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/06/2023] [Indexed: 01/09/2024]
Abstract
PURPOSE Ultrasound pupillometry (UP) is a potential alternative to video pupillometry (VP) for assessing changes in patients' pupillary diameter (ΔPD) due to surgical nociception, but the reproducibility of UP and VP has been unclear. We evaluated the reproducibility of nociceptive ΔPD measured with both methods. SUBJECTS AND METHODS This prospective observational trial with 15 healthy volunteers aged ≥ 18 years was conducted at a Japanese teaching hospital. The ΔPD due to tetanic stimuli randomly applied at 10-60 mA was measured with VP and UP. The primary outcome was the correlation between the ΔPD measured with VP and that measured with UP. The secondary outcome was the agreement between the methods. We also evaluated ΔPD pattern changes due to the raised pain intensity in each method. RESULTS The noxious ΔPD values of UP were weakly but significantly correlated with those of VP (Spearman's ρ = 0.38, p < 0.001). A significant constant error was identified between the two measurements (Bland-Altman: mean of the difference in ΔPD (VP - UP), - 0.4 [95% CI: - 0.52 to - 0.28, p < 0.001], generalized estimating equation: a beta estimator of ΔPD: 0.41, [95% CI: 0.26-0.56, p < 0.001]). The ΔPD pattern changes due to the raised tetanic stimuli were almost the same in the two methods. CONCLUSION Due to the significant constant error, we consider the reproducibility of the measured ΔPD between UP and VP moderate. Trial registry number UMIN 000047145. Prior to the subjects' enrollment, the trial was registered with the University Hospital Medical Information Network (Principal investigator: Mao Konno, Date of registration: 3.11.2022). https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000053778 .
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Affiliation(s)
- Mao Konno
- Department of Anesthesiology, Hirosaki University Hospital, 53 Honcho, Hirosaki, Aomori, 036-8563, Japan
| | - Hidetomo Niwa
- Department of Community Medicine for Perioperative Management, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan.
| | - Masato Kitayama
- Department of Surgery, Hirosaki University Hospital, 53 Honcho, Hirosaki, Aomori, 036-8563, Japan
| | - Kazuyoshi Hirota
- Department of Community Medicine for Perioperative Management, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan
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Romagnoli S, Lobo FA, Picetti E, Rasulo FA, Robba C, Matta B. Non-invasive technology for brain monitoring: definition and meaning of the principal parameters for the International PRactice On TEChnology neuro-moniToring group (I-PROTECT). J Clin Monit Comput 2024:10.1007/s10877-024-01146-1. [PMID: 38512360 DOI: 10.1007/s10877-024-01146-1] [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: 07/16/2023] [Accepted: 02/26/2024] [Indexed: 03/23/2024]
Abstract
Technologies for monitoring organ function are rapidly advancing, aiding physicians in the care of patients in both operating rooms (ORs) and intensive care units (ICUs). Some of these emerging, minimally or non-invasive technologies focus on monitoring brain function and ensuring the integrity of its physiology. Generally, the central nervous system is the least monitored system compared to others, such as the respiratory, cardiovascular, and renal systems, even though it is a primary target in most therapeutic strategies. Frequently, the effects of sedatives, hypnotics, and analgesics are entirely unpredictable, especially in critically ill patients with multiple organ failure. This unpredictability exposes them to the risks of inadequate or excessive sedation/hypnosis, potentially leading to complications and long-term negative outcomes. The International PRactice On TEChnology neuro-moniToring group (I-PROTECT), comprised of experts from various fields of clinical neuromonitoring, presents this document with the aim of reviewing and standardizing the primary non-invasive tools for brain monitoring in anesthesia and intensive care practices. The focus is particularly on standardizing the nomenclature of different parameters generated by these tools. The document addresses processed electroencephalography, continuous/quantitative electroencephalography, brain oxygenation through near-infrared spectroscopy, transcranial Doppler, and automated pupillometry. The clinical utility of the key parameters available in each of these tools is summarized and explained. This comprehensive review was conducted by a panel of experts who deliberated on the included topics until a consensus was reached. Images and tables are utilized to clarify and enhance the understanding of the clinical significance of non-invasive neuromonitoring devices within these medical settings.
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Affiliation(s)
- Stefano Romagnoli
- Department of Health Science, Section of Anesthesia and Critical Care, Department of Anesthesia and Critical Care, University of Florence, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Francisco A Lobo
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Edoardo Picetti, Parma University Hospital, Parma, Italy
| | - Frank A Rasulo
- Neuroanesthesia and Neurocritical Care Unit, Spedali Civili University affiliated hospital of Brescia, Brescia, Italy
| | - Chiara Robba
- IRCCS Policlinico San Martino, Genova, Italy
- Dipartimento di Scienze Chirurgiche Diagnostiche ed Integrate, Università di Genova, Genova, Italy
| | - Basil Matta
- Consultant in Anaesthesia, Trauma and Critical Care, Cambridge University Hospitals, Cambridge, England
- Assistant Professor - University of Cambridge, Cambridge, England
- Global Senior Medical Director - Masimo International Irvine, Irvine, CA, United States
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Huang H, Qiu Y, Gu G, Mei X, Pang L, Zhang C, Ran M, Li M. The value of pupillary diameter in evaluating pain perception after awakening in patients undergoing general anesthesia during orthopedic surgery. BMC Anesthesiol 2024; 24:61. [PMID: 38336612 PMCID: PMC10854081 DOI: 10.1186/s12871-024-02428-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The pupillary response to tetanic electrical stimulation reflects the balance between nociceptive stimulation and analgesia. Although pupillary pain index (PPI) was utilized to predict postoperative pain, it depended on tetanic stimulation and was complex. We aim to describe the potential relationship between PD in the presence of surgical stimulation and pain levels after awakening. METHODS According to the Verbal Rating Scale (VRS) score after extubation, the patients were divided into painless group (VRS = 0) and pain group (VRS ≥ 1). Pupillary diameter (PD) and pupillary light reflex velocity (PLRV) were compared between two groups when patients entered the operating room (T1), before incision (T2), 10 s after incision (T3), 30 s after incision (T4), 1 h after incision (T5), at the end of surgery (T6), shortly after extubation (T7), and when patients expressed pain clearly (T8). The magnitude of PD change (ΔPD) compared to the baseline value after anesthesia induction (T2) was calculated. The correlations between pupillary parameters and pain after awakening were calculated. RESULTS Patients with VRS ≥ 1 had greater PD than painless patients at T3-7 (P = 0.04, 0.04, 0.003, <0.001, <0.001), and it was positively correlated with VRS score after awakening at T4-7 (r = 0.188, 0.217, 0.684, 0.721). The ability of T6ΔPD to predict VRS ≥ 1 was strong [threshold: 20.53%, area under the curve (AUC): 0.93, 95% confidence interval (CI): 0.89-0.97 ]. CONCLUSION Our study indicates that PD is a useful index to direct the individualized analgesics used during operation, to better avoid the occurrence of pain during the postoperative emergence period. TRIAL REGISTRATION This study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2000040908, registration date: 15/12/2020).
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Affiliation(s)
- Huang Huang
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
| | - Yinuo Qiu
- Department of Anesthesiology, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China
| | - Guoxin Gu
- Department of Anesthesiology, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China
| | - Xiangyang Mei
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, 310014, Zhejiang, China
| | - Liwei Pang
- Department of Anesthesiology, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China
| | - Chuangxin Zhang
- Department of Anesthesiology, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China
| | - Mingzi Ran
- Department of Anesthesiology, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China.
| | - Mengmeng Li
- Department of Anesthesiology, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China.
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Favre E, Rahmaty Z, Ben-Hamouda N, Miroz JP, Abed-Maillard S, Rusca M, Oddo M, Ramelet AS. Nociception assessment with videopupillometry in deeply sedated intensive care patients: Discriminative and criterion validations. Aust Crit Care 2024; 37:84-90. [PMID: 37684156 DOI: 10.1016/j.aucc.2023.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Nociceptive assessment in deeply sedated patients is challenging. Validated instruments are lacking for this unresponsive population. Videopupillometry is a promising tool but has not been established in intensive care settings. AIM/OBJECTIVE To test the discriminate validity of pupillary dilation reflex (PDR) between non-noxious and noxious procedures for assessing nociception in non-neurological intensive care unit (ICU) patients and to test the criterion validity of pupil dilation using recommended PDR cut-off points to determine nociception. METHODS A single-centre prospective observational study was conducted in medical-surgical ICU patients. Two independent investigators performed videopupillometer measurements during a non-noxious and a noxious procedure, once a day (up to 7 days), when the patient remained deeply sedated (Richmond Agitation-Sedation Scale score: -5 or -4). The non-noxious procedures consisted of a gentle touch on each shoulder and the noxious procedures were endotracheal suctioning or turning onto the side. Bivariable and multivariable general linear mixed models were used to account for multiple measurements in same patients. Sensitivity and specificity, and areas under the curve of the receiver operating characteristic curve were calculated. RESULTS Sixty patients were included, and 305 sets of 3 measurements (before, during, and after), were performed. PDR was higher during noxious procedures than before (mean difference between noxious and non-noxious procedures = 31.66%). After testing all variables of patient and stimulation characteristics in bivariable models, age and noxious procedures were kept in the multivariable model. Adjusting for age, noxious procedures (coefficient = -15.14 (95% confidence interval = -20.17 to -15.52, p < 0.001) remained the only predictive factor for higher pupil change. Testing recommended cut-offs, a PDR of >12% showed a sensitivity of 65%, and a specificity of 94% for nociception prediction, with an area under the receiver operating curve of 0.828 (95% confidence interval = 0.779-0.877). CONCLUSIONS In conclusion, PDR is a potentially appropriate measure to assess nociception in deeply sedated ICU patients, and we suggest considering its utility in daily practices. REGISTRATION This study was not preregistered in a clinical registry. TWEETABLE ABSTRACT Pupillometry may help clinicians to assess nociception in deeply sedated ICU patients.
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Affiliation(s)
- Eva Favre
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland; Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland
| | - Zahra Rahmaty
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - John-Paul Miroz
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - Samia Abed-Maillard
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - Marco Rusca
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland
| | - Mauro Oddo
- Department of Intensive Care, Lausanne University Hospital and Lausanne University, Switzerland; Medical Directorate for Research, Education and Innovation, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, University of Lausanne and Lausanne University Hospital, Switzerland.
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11
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Ledowski T. [New Approaches in Perioperative Algesimetry]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:640-653. [PMID: 38056443 DOI: 10.1055/a-2006-9923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
The measurement of anaesthetic depth and muscle relaxation have been routine procedures during general anaesthesia for years. Quantification of intraoperative nociception, on the other hand, is still largely impossible. Various methods have been tested and commercialised for more than 10 years. However, a real breakthrough has not yet been achieved and the routine application of all methods available so far is not without problems. This article explains methodological similarities, but also points to specific aspects of various commercial solutions for perioperative algesimetry.
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12
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Hatsukawa H, Ishikawa M. Psychological states affecting initial pupil size changes after olfactory stimulation in healthy participants. Sci Rep 2023; 13:16050. [PMID: 37749199 PMCID: PMC10520065 DOI: 10.1038/s41598-023-43004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023] Open
Abstract
Odor perception affects physiological and psychological states. Pupillary light reflex (PLR) parameters can be affected by olfactory stimulation and psychological states, although it remains unclear whether the olfactory stimulation-induced psychological changes can associate with PLR parameter changes. This study aimed to investigate effects of olfactory stimulation-induced psychological changes on PLR parameter changes with repeated measurements. We collected data on six mood subscales of the profile of mood states, and on five PLR parameter measurements from 28 healthy participants. Participants underwent a 10-min olfactory stimulation on different days with six odorants available with the T&T olfactometer. As obtained data were clustered, we used linear mixed-effects models for statistical analyses. The olfactory stimulation using the no-odor liquid did not affect mood states and the initial pupil size (INIT). The sweat odorant worsened all mood subscales including fatigue-inertia (Fatigue)/Vigor-Activity (Vigor), and decreased INIT compared to the no-odor liquid. When comparing INIT responses related to changes in mood subscales between the no-odor liquid and the sweat odorant, worsened states of Fatigue/Vigor were associated with decreased INIT in the sweat odorant. Fatigue/Vigor can be used as mental fatigue indicators. Thus, mental fatigue can be associated with decreased INIT in the olfactory stimulation.
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Affiliation(s)
- Hiroatsu Hatsukawa
- Department of Otolaryngology, Head and Neck Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwachou, Amagasaki, Hyogo Prefecture, 660-8550, Japan
| | - Masaaki Ishikawa
- Department of Otolaryngology, Head and Neck Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwachou, Amagasaki, Hyogo Prefecture, 660-8550, Japan.
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13
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Singh A, Akhileshwar, Kumar N, De RR, Bahadur R, Shekhar S. The Role of Pupillometry in the Assessment of Pain in Children Under General Anesthesia: A Prospective Single-Blinded Observational Study. Cureus 2023; 15:e43894. [PMID: 37753025 PMCID: PMC10518524 DOI: 10.7759/cureus.43894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
Background and objective The management and treatment of nociception remain one of the major challenges in anesthesiology, and hemodynamic variations may occur due to inadequate analgesia, which at times can be injurious. Pupillometry is a new noninvasive tool to assess nociception during anesthesia. The amount of pupillary reflex dilation (PRD) is directly proportional to the intensity of nociceptive stimuli and inversely proportional to the opioid dosage. This study aimed to assess the use of pupillometry as reflex pupillary dilatation in response to surgical stimulus in children under general anesthesia and to guide intraoperative opioid consumption. Materials and methods After obtaining approval from the institutional ethics committee and written consent from parents, children with an American Society of Anesthesiology (ASA) classification of I and II and aged 2-12 years who were undergoing surgery under general anesthesia were enrolled in this prospective randomized observational study. General anesthesia was standardized with propofol, sevoflurane, and O2 and N2O (50:50%), and fentanyl administration was guided by pupil diameter changes. The primary outcome was to measure pupillary dilatation in response to pain and fentanyl administration guided by it. Results A total of 72 patients were included in the study. The mean pupil diameter significantly increased after surgical stimulus from 1.37 ±0.87 to 2.40 ±1.95 mm (p<0.001). The heart rate (116.2 ±12.25 to 118.50 ±8.20 beats/minute, p=0.18) and systolic BP (114.60 ±17.73 to 118.50 ±12.25 mmHg, p=0.12) did not change significantly on stimulus. The mean fentanyl consumption was 2.4 ug/kg and the side effects were not remarkable. Conclusion Based on our findings, pain has a significant influence on the pupil dilatation reflex in anesthetized children, and opioid administration based on pupil diameter can be valuable in clinical settings. We recommend the use of pupillometry as a pain index in children undergoing surgery under general anesthesia, and it can be a beneficial tool for assessing intraoperative pain. Newer techniques and developments are required in this field.
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Affiliation(s)
- Akrity Singh
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Akhileshwar
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Nitin Kumar
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Ranjeet Rana De
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Raj Bahadur
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Saurav Shekhar
- Department of Trauma and Emergency Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
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14
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Grandin T, Velarde A, Strappini A, Gerritzen M, Ghezzi M, Martínez-Burnes J, Hernández-Ávalos I, Domínguez-Oliva A, Casas-Alvarado A, Mota-Rojas D. Slaughtering of Water Buffalo ( Bubalus bubalis) with and without Stunning: A Focus on the Neurobiology of Pain, Hyperalgesia, and Sensitization. Animals (Basel) 2023; 13:2406. [PMID: 37570215 PMCID: PMC10417361 DOI: 10.3390/ani13152406] [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: 06/13/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 08/13/2023] Open
Abstract
The slaughter process in livestock is considered a stressor where the transport and handling of animals, as well as the selected stunning and bleeding methods, can cause acute pain, distress, and suffering. In water buffaloes, although stunning is known to be performed before bleeding to induce unconsciousness, no emphasis is made on the nociceptive events during this process. Particularly, current mechanical stunning methods applied to cattle are unsuitable for water buffaloes due to anatomical differences in the skull from other large ruminants. Furthermore, although very high-pressure pneumatic (200-220 psi) may be effective in the frontal position for lighter-weight water buffalos, for heavier animals, it is less likely to be effective. The present review aims: (1) to analyze the anatomical particularities of water buffaloes to discuss the importance of selecting a stunning method suitable for buffaloes, and (2) to revise the potential pain-related consequences, such as hyperalgesia and sensitization, and the signs to assess the stun quality and death to comprehend the relevance of a proper technique according to the species.
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Affiliation(s)
- Temple Grandin
- Department of Animal Science, Colorado State University, Fort Collins, CO 80526, USA;
| | - Antonio Velarde
- Animal Welfare Program, Institute of Agrifood Research and Technology (IRTA), Veinat Sies S-N, 17121 Monells, Spain;
| | - Ana Strappini
- Animal Health & Welfare, Wageningen Livestock Research, Wageningen University & Research, 6708 WD Wageningen, The Netherlands; (A.S.); (M.G.)
| | - Marien Gerritzen
- Animal Health & Welfare, Wageningen Livestock Research, Wageningen University & Research, 6708 WD Wageningen, The Netherlands; (A.S.); (M.G.)
| | - Marcelo Ghezzi
- Animal Welfare Area, Faculty of Veterinary Sciences (FCV), Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), University Campus, Tandil 7000, Argentina;
| | - Julio Martínez-Burnes
- Facultad de Medicina Veterinaria y Zootecnia, Universidad Autónoma de Tamaulipas, Victoria City 87000, Mexico
| | - Ismael Hernández-Ávalos
- Clinical Pharmacology and Veterinary Anesthesia, FESC, Universidad Nacional Autónoma de México (UNAM), Cuautitlán Izcalli 54714, Mexico
| | - Adriana Domínguez-Oliva
- Neurophysiology, Behavior and Animal Welfare Assessment, DPAA, Universidad Autónoma Metropolitana (UAM), Mexico City 04960, Mexico
| | - Alejandro Casas-Alvarado
- Neurophysiology, Behavior and Animal Welfare Assessment, DPAA, Universidad Autónoma Metropolitana (UAM), Mexico City 04960, Mexico
| | - Daniel Mota-Rojas
- Neurophysiology, Behavior and Animal Welfare Assessment, DPAA, Universidad Autónoma Metropolitana (UAM), Mexico City 04960, Mexico
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15
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Bertolizio G, Molliex S, Richebé P. Evaluation of nociception: if one parameter can do so little, can multiple parameters do so much? Anaesth Crit Care Pain Med 2023; 42:101236. [PMID: 37116863 DOI: 10.1016/j.accpm.2023.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Gianluca Bertolizio
- Department of Pediatric Anesthesiology, Montreal Children's Hospital, Montreal, QC H4A 3J1, Canada; Research Institute, McGill University Health Centre, Montreal, QC H4A 3J1, Canada; Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada.
| | - Serge Molliex
- Université Saint Etienne, Département d'Anesthésie-Réanimation CHU Saint Etienne, Inserm Sainbiose U1059, F-42023, Saint Etienne, France
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal, Montreal, QC, H1T 2M4, Canada; Research Center of Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal, Montreal, QC, H1T 2M4, Canada; Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, H3T 1J4
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16
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Pouzot-Nevoret C, Junot S, Goffette L, Bonnet-Garin JM, Allaouchiche B, Magnin M. Use of pupillometry for the evaluation of analgesia in dogs hospitalized in intensive care: A prospective study. Res Vet Sci 2023; 158:96-105. [PMID: 36965258 DOI: 10.1016/j.rvsc.2023.03.014] [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: 12/09/2022] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 03/27/2023]
Abstract
A prospective study was performed on hospitalized conscious dogs. The objectives were: 1) to evaluate the feasibility and reliability of portable infrared pupillometry using a measure of photo light reflexes, 2) to identify parameters influencing measures, and 3) to compare parameters before and after the administration of analgesia. Twenty-nine dogs were included. Pupillometry was feasible by a single person. There was an excellent reliability for the evaluation of pupil diameter. There was poor to good reliability for the other parameters. There was an association between weight and mean pupil diameter (estimate = 0.1 mm, CI95 = [0.0; 0.1], P = 0.02), mean diameter variation (estimate = 0.2%, CI95 = [0.0; 0.4], P = 0.01), and mean velocity (estimate = 0.08 ms, CI95 = [0.03; 0.13], P = 0.002). Male dogs had a significantly larger mean pupil diameter than females (estimate = 1.3 mm, CI95 = [0.1; 2.5], P = 0.03). Independently of weight and sex, there was an association between mean pupil diameter and pain score: the higher the pain score, the lower the mean pupil diameter. There was a correlation between mean pupil diameter and morphine dose (ρ = -0.78, P = 0.0004). There was no significant difference in pupil diameter, velocity, and latency before and after analgesic administration. In conclusion, results do not support the use of PLR measurement by pupillometry as a pain assessment technique in hospitalized conscious dogs.
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Affiliation(s)
- Céline Pouzot-Nevoret
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat F-69280 Marcy L'Etoile, France; Université de Lyon, VetAgro Sup, Soins Intensifs Anesthésie et Médecine d'Urgence (SIAMU), 1 avenue Bourgelat F-69280 Marcy l'Etoile, France.
| | - Stéphane Junot
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat F-69280 Marcy L'Etoile, France; Université de Lyon, VetAgro Sup, Anesthésiologie, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France.
| | - Léa Goffette
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat F-69280 Marcy L'Etoile, France.
| | - Jeanne-Marie Bonnet-Garin
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat F-69280 Marcy L'Etoile, France; Université de Lyon, VetAgro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France.
| | - Bernard Allaouchiche
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat F-69280 Marcy L'Etoile, France; Université de Lyon, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Réanimation Médicale, 165 Chemin du Grand Revoyet F-69310 Pierre-Bénite, France
| | - Mathieu Magnin
- Université de Lyon, UR APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis, UP 2021.A101, VetAgro Sup, 1 Avenue Bourgelat F-69280 Marcy L'Etoile, France; Université de Lyon, VetAgro Sup, Unité de Physiologie, Pharmacodynamie et Thérapeutique, 1 avenue Bourgelat F-69280 Marcy l'Etoile, France.
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17
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Mondardini MC, Sperotto F, Daverio M, Amigoni A. Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view. Eur J Pediatr 2023; 182:2013-2026. [PMID: 36892607 DOI: 10.1007/s00431-023-04905-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/14/2023] [Accepted: 02/26/2023] [Indexed: 03/10/2023]
Abstract
In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.
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Affiliation(s)
- Maria Cristina Mondardini
- Pediatric Anesthesia and Intensive Care Unit, Department of Woman's and Child's Health, IRCCS University Hospital of Bologna Policlinico S. Orsola, Bologna, Italy
| | - Francesca Sperotto
- Cardiovascular Critical Care Unit, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marco Daverio
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy.
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18
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Bauerschmidt A, Al-Bermani T, Ali S, Bass B, Dorilio J, Rosenberg J, Al-Mufti F. Modern Sedation and Analgesia Strategies in Neurocritical Care. Curr Neurol Neurosci Rep 2023; 23:149-158. [PMID: 36881257 DOI: 10.1007/s11910-023-01261-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE OF REVIEW Patients with acute neurologic injury require a specialized approach to critical care, particularly with regard to sedation and analgesia. This article reviews the most recent advances in methodology, pharmacology, and best practices of sedation and analgesia for the neurocritical care population. RECENT FINDINGS In addition to established agents such as propofol and midazolam, dexmedetomidine and ketamine are two sedative agents that play an increasingly central role, as they have a favorable side effect profile on cerebral hemodynamics and rapid offset can facilitate repeated neurologic exams. Recent evidence suggests that dexmedetomidine is also an effective component when managing delirium. Combined analgo-sedation with low doses of short-acting opiates is a preferred sedation strategy to facilitate neurologic exams as well as patient-ventilator synchrony. Optimal care for patients in the neurocritical care population requires an adaptation of general ICU strategies that incorporates understanding of neurophysiology and the need for close neuromonitoring. Recent data continues to improve care tailored to this population.
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Affiliation(s)
- Andrew Bauerschmidt
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
- Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
| | - Tarik Al-Bermani
- Department of Pulmonary, Critical Care, and Sleep Medicine-Westchester Medical Center, Valhalla, NY, USA
| | - Syed Ali
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Brittany Bass
- Department of Pulmonary, Critical Care, and Sleep Medicine-Westchester Medical Center, Valhalla, NY, USA
| | - Jessica Dorilio
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jon Rosenberg
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
- Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
- Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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19
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Bertolizio G, Garbin M, Ingelmo PM. Evaluation of Nociception during Pediatric Surgery: A Topical Review. J Pers Med 2023; 13:260. [PMID: 36836492 PMCID: PMC9964458 DOI: 10.3390/jpm13020260] [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: 01/02/2023] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/03/2023] Open
Abstract
The association between intraoperative nociception and increased patient's morbidity is well established. However, hemodynamic parameters, such as heart rate and blood pressure, may result in an inadequate monitor of nociception during surgery. Over the last two decades, different devices have been marketed to "reliably" detect intraoperative nociception. Since the direct measure of nociception is impractical during surgery, these monitors measures nociception surrogates such as sympathetic and parasympathetic nervous systems responses (heart rate variability, pupillometry, skin conductance), electroencephalographic changes, and muscular reflex arc. Each monitor carries its own advantages and disadvantages. The manuscript aims to give an overview of the most up-to-date information available in the literature on current nociceptor monitors available in clinical practice, with particular focus on their applications in pediatrics.
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Affiliation(s)
- Gianluca Bertolizio
- Department of Pediatric Anesthesiology, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada
- Research Institute, McGill University Health Center, Montreal, QC H4A 3J1, Canada
| | - Marta Garbin
- Department of Clinical Sciences, Université de Montréal, St-Hyacinthe, QC J2S 2M2, Canada
| | - Pablo M. Ingelmo
- Department of Pediatric Anesthesiology, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H4A 3J1, Canada
- Research Institute, McGill University Health Center, Montreal, QC H4A 3J1, Canada
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children’s Hospital, Montreal, QC H4A 3J1, Canada
- Alan Edwards Center for Research on Pain, McGill University, Montreal, QC H3A 2B4, Canada
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20
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The median effective concentration of remifentanil to inhibit pupillary reflex dilation induced by endotracheal intubation. Am J Transl Res 2022; 14:7898-7906. [PMID: 36505339 PMCID: PMC9730105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/15/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the median effective concentration (EC50) of remifentanil to inhibit pupillary reflex dilation (PRD) induced by endotracheal intubation using a modified sequential test method. METHODS In this prospective study, 34 patients undergoing elective surgery under general anesthesia were selected. The induction of anesthesia was started using propofol with an effect-site concentration (Ce(pro)) of 4.0 μg/mL. The effect-site concentration of remifentanil (Ce(Remi)) was set according to the modified sequential test method, with 0.42 ng/mL as the initial concentration for the first patient. The gradient ratio was 1.1. The Ce(Remi) of each patient was determined by whether the PRD of the previous patient disappeared during endotracheal intubation. If the PRD disappeared, a lower concentration was applied. Otherwise, a higher concentration was applied. The experiment ended after 9 crosses of PRD disappearance-presence and PRD presence-disappearance. The EC50 of remifentanil and 95% confidence interval (CI) were calculated using the Dixon and Massey's method. The Probit regression procedure was used to derive the EC50, 95% effective concentration (EC95) of remifentanil and their 95% CIs. RESULTS The EC50 of remifentanil to inhibit PRD induced by endotracheal intubation was 4.41 ng/mL (95% CI, 4.32 to 4.49 ng/mL) and the EC95 was 5.24 ng/mL (95% CI, 4.78 to 7.68 ng/mL). In 34 patients, the time to reach the maximum change in heart rate, systolic blood pressure, mean arterial pressure and Bispectral index was 75.00 (60.00-98.00) s, 95.00 (75.00-133.00) s, 95.00 (75.00-135.00) s, and 100.00 (78.00-113.00) s, respectively, which was significantly longer than the time (42.00 (25.00-47.00) s) needed for pupillary diameter (P<0.05). CONCLUSION The EC50 of remifentanil to inhibit PRD induced by endotracheal intubation was 4.41 ng/mL and the EC95 was 5.24 ng/mL. The time to reach the maximum pupillary diameter change was shorter than the time needed for heart rate, blood pressure, and Bispectral index. This prospective study was registered in the China Clinical Trials Registration Center (ChiCTR2100043771, https://www.chictr.org.cn).
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Mills EP, Combs-Ramey K, Kwong GPS, Pang DSJ. Development of reference intervals for pupillometry in healthy dogs. Front Vet Sci 2022; 9:1020710. [PMID: 36387393 PMCID: PMC9643214 DOI: 10.3389/fvets.2022.1020710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/03/2022] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Pupillometry, the measurement of pupil size and reactivity to a stimulus, has various uses in both human and veterinary medicine. These reflect autonomic tone, with the potential to assess nociception and emotion. Infrared pupillometry reduces inaccuracies that may occur when the pupillary light reflex is determined subjectively by the examiner. To our knowledge, there are no published studies outlining normal reference intervals for automated pupillometry in dogs. OBJECTIVE The objective of this study was to develop de novo automated pupillometry reference intervals from 126 healthy canine eyes. METHODS The pupillary light reflex (PLR) was measured with a handheld pupillometer (NeurOptics™ PLR-200™ Pupillometer). Parameters recorded included maximum pupil diameter (MAX), minimum pupil diameter (MIN), percent constriction (CON), latency (LAT), average constriction velocity (ACV), maximum constriction velocity (MCV), average dilation velocity (ADV) and time to 75% pupil diameter recovery (T75). One measurement was obtained for each eye. RESULTS The following reference intervals were developed: MAX (6.05-11.30 mm), MIN (3.76-9.44 mm), CON (-37.89 to -9.64 %), LAT (0.11-0.30 s), ACV (-6.39 to -2.63 mm/ s), MCV (-8.45 to -3.75 mm/s), ADV (-0.21-1.77 mm/s), and T75 (0.49-3.20 s). CLINICAL SIGNIFICANCE The reference intervals developed in this study are an essential first step to facilitate future research exploring pupillometry as a pain assessment method in dogs.
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Affiliation(s)
- Erinn P. Mills
- Western Veterinary Specialist and Emergency Centre, Calgary, AB, Canada
| | | | - Grace P. S. Kwong
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Daniel S. J. Pang
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
- Faculty of Veterinary Medicine, Université de Montréal, St Hyacinthe, QC, Canada
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22
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Vlaenderen DV, Hans G, Saldien V, Wildemeersch D. Pupillary reflex dilation and pain index evaluation during general anesthesia using sufentanil: a double-blind randomized controlled trial. Pain Manag 2022; 12:931-941. [PMID: 36189668 DOI: 10.2217/pmt-2022-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: In a single-center, double-blind, randomized controlled trial, we evaluated whether pupillometry-controlled use of sufentanil is better than free-choice administration of sufentanil by anesthesiologists. Patients & methods: 61 patients undergoing daycare gynecological or abdominal surgery were enrolled. A pupillometry pain index score chart was introduced for administration guidance of sufentanil. Results: The first objective, patient well-being, did not show a significant difference with painkiller usage and health state index at day 1 postoperatively. Secondly, we experienced difficulty in interpretation of the pupillometry score. Thirdly, opioid usage was higher in the intervention group (20.1 vs 14.8 mcg; p = 0.017). Conclusion: The use of pupillometry and pain index chart for bolus sufentanil with our protocol showed an unwanted higher sufentanil usage without a significant difference in patient wellbeing. (Ethics Committee EC17/28/319 of the University Hospital of Antwerp. Registration at clinicaltrials.gov NCT03248908.).
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Affiliation(s)
- Diederik Van Vlaenderen
- Department of Anesthesia, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Guy Hans
- Multidisciplinary Pain Centre, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Vera Saldien
- Department of Anesthesia, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650 Edegem, Belgium
| | - Davina Wildemeersch
- Department of Anesthesia, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650 Edegem, Belgium.,Multidisciplinary Pain Centre, Antwerp University Hospital (UZA), Drie Eikenstraat 655, 2650 Edegem, Belgium
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Hatsukawa H, Ishikawa M. Decreased initial pupil size and shortened constriction latency due to negative mood states and mental fatigue in clinical subacute pain models. Physiol Behav 2022; 253:113850. [PMID: 35598830 DOI: 10.1016/j.physbeh.2022.113850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 11/18/2022]
Abstract
Previous clinical studies on pupillary light reflex parameters showed shortened constriction latency (LAT) and decreased initial pupil size (INIT) due to increased numeric rating scale (NRS) scores, reflecting subjective pain intensity, in subacute pain models. As noxious stimulation causes pupil dilation, decreased INIT (pupil constriction) was an unexpected finding. Pain-related negative moods and mental fatigue might have caused this finding. We aimed to investigate how psychological states affect LAT/INIT in two subacute pain models. For psychological assessment, we used the Profile of Mood States (POMS) and calculated the total mood disturbance (TMD) score using six mood categories. We collected data on NRS scores, POMS-related scores, LAT, and INIT through a longitudinal study. Using linear mixed-effects models, we evaluated the association of TMD scores with NRS scores, LAT, and INIT. Furthermore, we performed subanalyses targeting two mood categories that represent mental fatigue: Fatigue-Inertia (Fatigue) and Vigor-Activity (Vigor). We investigated whether obtained results can be identical in both models. In total, 141 patients were enrolled. Increased NRS scores were associated with increased TMD/Fatigue scores and decreased Vigor scores, being associated with shortened LAT/decreased INIT in both models. Score changes in NRS, TMD, Fatigue, and Vigor indicated that increased subjective pain intensity can be associated with negative mood states, especially mental fatigue. This study revealed that negative moods and mental fatigue induced by acute pain can be associated with shortened LAT/decreased INIT in both models, indicating clinical potential of LAT/INIT as objective indicators reflecting the psychological states for pain assessment.
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Affiliation(s)
- Hiroatsu Hatsukawa
- Department of Otolaryngology, Head and Neck Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwachou, Hyogo Prefecture, Amagasaki 660-8550, Japan
| | - Masaaki Ishikawa
- Department of Otolaryngology, Head and Neck Surgery, Hyogo Prefectural Amagasaki General Medical Center, 2-17-77 Higashinaniwachou, Hyogo Prefecture, Amagasaki 660-8550, Japan.
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24
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Hatsukawa H, Ishikawa M. Clinical potential of pupillary light reflex and heart rate variability parameters as objective indicators of tonsillectomy-induced pain. Physiol Meas 2022; 43. [PMID: 35245910 DOI: 10.1088/1361-6579/ac5ae6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/04/2022] [Indexed: 11/12/2022]
Abstract
Establishing objective indicators of subjective pain intensity is important in pain assessment. Pupillary light reflex (PLR) and heart rate variability (HRV) indicate autonomic nervous system (ANS) activity and may serve as pain indicators because pain can affect ANS activity. In this prospective longitudinal study, we aimed to investigate the potential of PLR/HRV parameters as objective indicators of subjective pain intensity after tonsillectomy. Sixty-seven patients undergoing tonsillectomy were enrolled. Subjective pain intensity based on a numeric rating scale (NRS) and eight PLR/HRV parameters were assessed at five time points. We investigated the changes in the NRS values over time. We estimated regression coefficients reflecting parameter changes per unit change in the NRS score using linear mixed-effects models. The mean NRS score was 0 at two pre-surgery time points, 5 on postoperative days (PODs) 1 and 2, and 0 at postoperative week 3. Two parameters (initial pupil size [INIT] and constriction latency [LAT]) showed significant changes on POD1 and POD2 in comparison to baseline data measured at the pre-surgery time point. Among these parameters, only LAT showed no significant changes between POD1 and POD2. Significant regression coefficients with the narrowest 95% confidence intervals were observed for INIT and LAT. Increased NRS scores were associated with decreased INIT and shortened LAT. LAT was a robust indicator of subjective pain intensity. Our patients showed decreased INIT with increased NRS scores, indicating the predominance of the parasympathetic, not sympathetic, tone in pupils. Further studies are required to investigate factors causing this predominance.
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Affiliation(s)
- Hiroatsu Hatsukawa
- Department of Otolaryngology, Head and Neck Surgery, Hyogo Prefectural Amagasaki General Medical Center, Higashinannbachou 2-17-77, Amagasaki, 660-8550, JAPAN
| | - Masaaki Ishikawa
- Department of Otolaryngology, Head and Neck Surgery, Hyogo Prefectural Amagasaki General Medical Center, Higashinannbachou 2-17-77, Amagasaki, 660-8550, JAPAN
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Solyman O, Abushanab MMI, Carey AR, Henderson AD. Pilot Study of Smartphone Infrared Pupillography and Pupillometry. Clin Ophthalmol 2022; 16:303-310. [PMID: 35173409 PMCID: PMC8840836 DOI: 10.2147/opth.s331989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/19/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Omar Solyman
- Research Institute of Ophthalmology, Giza, Egypt
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Ophthalmology, Qassim University Medical City, Al-Qassim, Saudi Arabia
- Correspondence: Omar Solyman, Tel +20 1009350101, Email
| | | | - Andrew R Carey
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amanda D Henderson
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Fang PP, Wu JQ, Tang LL, Gao S, Liu XS. The association between perioperative pupillary parameters and postoperative acute pain: A pilot cross-sectional study. Pain Pract 2021; 22:322-328. [PMID: 34662477 DOI: 10.1111/papr.13084] [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: 08/09/2021] [Revised: 09/25/2021] [Accepted: 10/12/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We aim to explore the capacity of perioperative pupillary variables to predict acute pain in the post-anesthesia care unit (PACU). METHODS Patients scheduled to undergo thoracic or abdominal surgery under general anesthesia between April 2021 and June 2021 were enrolled. We measured the pupil diameter, pupillary light reflex (PLR), and pupillary reflex dilatation 5 min before anesthesia induction (T1), 5 min after intubation (T2), at the end of anesthesia (T3), immediately before extubation (T4), and 5 min after extubation (T5). We assessed the early postoperative pain intensity in the PACU using Numeric Rating Scales (NRS) at recovery, 5 min after recovery, and 10 min after recovery. Logistic regression models were used to evaluate the association between perioperative pupillary variables and postoperative pain intensity. RESULTS Fifty-one patients were enrolled, 50 of whom were included in the final analysis. A total of 13 patients (26%) needed remedial analgesia in the PACU. Pupil parameters at T1, T2, T3, and T5 were not associated with NRS in the PACU. Multiple logistic regression models and receiver operating characteristic (ROC) curves indicated that only latency of PLR at T4 can predict postoperative acute pain. The ROC analysis showed that the cutoff value for latency of PLR at T4 was 0.29 s to discriminate between no pain and pain, and the area under the curve was 0.778 (95% CI 0.634-0.922, p = 0.002) with sensitivity 50.0% and specificity 91.7%. CONCLUSION The latency of PLR immediately before extubation may be a useful predictor for postoperative acute pain in the PACU.
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Affiliation(s)
- Pan-Pan Fang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jun-Qi Wu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Li-Li Tang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Shan Gao
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei, China
| | - Xue-Sheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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