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McKay RE, Kohn M, Schwartz E, Larson MD. Population study of pupillary unrest in ambient light. Auton Neurosci 2024; 254:103197. [PMID: 38996657 DOI: 10.1016/j.autneu.2024.103197] [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: 02/14/2024] [Revised: 05/17/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024]
Abstract
INTRODUCTION Pupillary unrest in ambient light (PUAL) describes the fluctuation of pupil diameter observed in normal, awake subjects under typical levels of indoor light. PUAL becomes low to absent in young healthy subjects during opioid intoxication. We sought to determine the age-related distribution of PUAL values in a random sample of ambulatory participants. METHODS Subjects ≥18 years of age were recruited. All were identified by age range (18-29, 30-49, 50-69, and ≥70), and surveyed for diabetes, beta-blocker use, and prior 24-hour opioid use. Relationship between mean PUAL, age group, comorbidity and opioid use were examined by Kruskal Wallis test, and PUAL and was modeled using stepwise multilevel linear regression, including diabetes, beta blocker use, prior 24-hour opioid use, autonomic dysfunction, and pupil diameter as fixed effects and subject as random effect. RESULTS Among 150 subjects, 17 reported diabetes, 12 reported beta-blocker use, 14 reported prior 24-hour opioid use, and 120 reported no comorbid conditions. PUAL declined in higher age categories (by 0.0307, P < 0.001), with diabetes (by 0.0481, P = 0.025), and with beta-blocker use (by 0.0616, P = 0.005). Opioid related PUAL decline was observed, but statistical significance varied by model. Among healthy subjects, no PUAL value fell within range indicating high likelihood of opioid toxicity based on previous data from healthy subjects undergoing opioid infusion. CONCLUSION PUAL declined in higher age groups, diabetes and beta-blocker use, conditions associated with impaired autonomic function, and with opioid use but significance varied depending on the chosen model.
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Affiliation(s)
- Rachel Eshima McKay
- Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), San Francisco, CA, United States of America.
| | - Michael Kohn
- Department of Epidemiology and Biostatistics, University of California San Francisco (UCSF), San Francisco, CA, United States of America
| | - Elliot Schwartz
- Department of Anesthesiology, Cedar Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, United States of America
| | - Merlin D Larson
- Department of Anesthesia and Perioperative Care, University of California San Francisco (UCSF), San Francisco, CA, United States of America
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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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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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Gregoire C, Charier D, de Bergeyck R, Mouraux A, Van Ouytsel F, Lambert R, Zhou N, Lavand'homme P, Penaloza A, Pickering G. Comparison between pupillometry and numeric pain rating scale for pain assessments in communicating adult patients in the emergency department. Eur J Pain 2023; 27:952-960. [PMID: 37303073 DOI: 10.1002/ejp.2137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The adequate assessment of pain in the emergency department (ED) can be challenging. Two dynamic pupillary measures used in conscious subjects after a surgical procedure were previously shown to correlate to the magnitude of ongoing pain. The objective of this study was to test the ability of dynamic measures derived from pupillometry to evaluate pain intensity in conscious adult patients admitted to the ED. METHODS This prospective, interventional, single-centre study was performed between August 2021 and January 2022 (NCT05019898). An assessment of self-reported pain intensity was performed on ED admission by the triage nurse using a numeric rating scale (NRS). This was followed by two dynamic measures derived from pupillometry that were previously correlated with pain perception: the pupillary unrest under ambient light (PUAL) and the pupillary light reflex (PLR). RESULTS Among the 313 analysed patients, the median age was 41 years, and 52% were women. No correlation was found between self-reported pain ratings and PUAL (r = 0.007) or PLR (baseline diameter r = -0.048; decrease r = 0.024; latency r = 0.019; slope = -0.051). Similarly, the pupillometry measures could not discriminate patients with moderate to severe pain (defined as NRS ≥4). CONCLUSIONS Pupillometry does not appear to be an effective tool to evaluate pain in the ED environment. Indeed, too many factors influencing the sympathetic system-and thus the dynamic pupillary measures-are not controllable in the ED. SIGNIFICANCE Pupillometry does not appear to be an effective tool to evaluate pain in the ED environment. There are several possible explanations for these negative results. The factors influencing the sympathetic system-and thus the PD fluctuations-are controllable in the postoperative period but not in the ED (e.g. full bladder, hypothermia). In addition, numerous psychological phenomena can impact pupillometry measurements such as emotional reactions or cognitive tasks. These phenomena are particularly difficult to control in the ED environment.
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Affiliation(s)
- Charles Gregoire
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Institute of Neuroscience (IoNS), UCLouvain, Brussels, Belgium
| | - David Charier
- Department of Anesthesiology, University Jean Monnet, University Hospital of Saint-Etienne, INSERM, Saint-Etienne, France
| | - Romane de Bergeyck
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - André Mouraux
- Institute of Neuroscience (IoNS), UCLouvain, Brussels, Belgium
| | - Floor Van Ouytsel
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Romain Lambert
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Nicole Zhou
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Patricia Lavand'homme
- Anesthesiology Department, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Andrea Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gisele Pickering
- Clinical Pharmacology Department, PIC/CIC Inserm 1405-University Hospital CHU, Clermont-Ferrand, France
- Fundamental and Clinical Pharmacology of Pain, Faculty of Medicine, Clermont Auvergne University, Clermont-Ferrand, France
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Neice A, Ma T, Chang K. Relationship between age, sex and pupillary unrest. J Clin Monit Comput 2022; 36:1897-1901. [PMID: 35438364 DOI: 10.1007/s10877-022-00858-6] [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: 01/19/2022] [Accepted: 03/29/2022] [Indexed: 02/02/2023]
Abstract
Pupllary unrest in ambient light (PUAL) is the chaotic fluctuation of pupil diameter about its mean value. The degree of fluctuation is typically measured using a pupillometer and quantified using an index that sums fluctuations in a frequency range of interest. Indices that measure PUAL show promise in predicting effects of sedative or opioid drugs. Because PUAL is mediated by the parasympathetic nervous system, it would be expected to decline with age-related decreases in parasympathetic tone. In this study we measured average PUAL in 16 subjects from age 3 to 72, with at least 3 repeated measurements on each subject, each taken for approximately 10 s, at approximately 30 frames per second, with illumination of the ipsilateral eye. PUAL was calculated using the algorithm of the Neurolight pupillometer. We found that average PUAL typically declines by approximately 1% per year, and that the standard deviation of repeated measurements is approximately 20%. We therefore conclude that repeated, averaged measurements of age-normed PUAL are likely to be much more clinically useful than single, uncorrected values.
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Affiliation(s)
- Andrew Neice
- Legacy Meridian Park Hospital, 19300 SW 65th Ave, 97062, Tualatin, OR, USA.
| | - Tony Ma
- Benten Technologies, Manassas, VA, USA
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Chan WP, Prescott BR, Barra ME, Chung DY, Kim IS, Saglam H, Hutch MR, Shin M, Zafar SF, Benjamin EJ, Smirnakis SM, Dupuis J, Greer DM, Ong CJ. Dexmedetomidine and Other Analgosedatives Alter Pupil Characteristics in Critically Ill Patients. Crit Care Explor 2022; 4:e0691. [PMID: 35783547 PMCID: PMC9243241 DOI: 10.1097/cce.0000000000000691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
In critically ill patients with neurologic disease, pupil examination abnormalities can signify evolving intracranial pathology. Analgesic and sedative medications (analgosedatives) target pupillary pathways, but it remains unknown how analgosedatives alter pupil findings in the clinical care setting. We assessed dexmedetomidine and other analgosedative associations with pupil reactivity and size in a heterogeneous cohort of critically ill patients with acute intracranial pathology. DESIGN Retrospective cohort study. SETTING Two neurologic ICUs between 2016 and 2018. PATIENTS Critically ill adult patients with pupil measurements within 60 minutes of analgosedative administration. Patients with a history of intrinsic retinal pathology, extracranial injury, inaccessible brain imaging, or no Glasgow Coma Scale (GCS) data were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used mixed-effects linear regression accounting for intrapatient correlations and adjusting for sex, age, GCS score, radiographic mass effect, medication confounders, and ambient light. We tested the association between an initiation or increased IV infusion of dexmedetomidine and pupil reactivity (Neurologic Pupil Index [NPi]) and resting pupil size (mm) obtained using NeurOptics NPi-200 (NeurOptics, Irvine, CA) pupillometer. Of our 221 patients with 9,897 pupil observations (median age, 60 [interquartile range, 50-68]; 59% male), 37 patients (166 pupil observations) were exposed to dexmedetomidine. Dexmedetomidine was associated with higher average NPi (β = 0.18 per 1 unit increase in rank-normalized NPi ± 0.04; p < 0.001) and smaller pupil size (β = -0.25 ± 0.05; p < 0.001). Exploratory analyses revealed that acetaminophen was associated with higher average NPi (β = 0.04 ± 0.02; p = 0.02) and that most IV infusion analgosedatives including propofol, fentanyl, and midazolam were associated with smaller pupil size. CONCLUSIONS Dexmedetomidine is associated with higher pupil reactivity (high NPi) and smaller pupil size in a cohort of critically ill patients with neurologic injury. Familiarity with expected pupil changes following analgosedative administration is important for accurate interpretation of pupil examination findings, facilitating optimal management of patients with acute intracranial pathology.
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Affiliation(s)
- Wang Pong Chan
- Department of Neurology, Boston University School of Medicine, Boston, MA
| | - Brenton R Prescott
- Department of Neurology, Boston University School of Medicine, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
- Department of Neurology, Brigham & Women's Hospital, Boston, MA
| | - Megan E Barra
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - David Y Chung
- Department of Neurology, Boston Medical Center, Boston, MA
| | - Ivy S Kim
- Department of Neurology, Boston University School of Medicine, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
- Department of Neurology, Brigham & Women's Hospital, Boston, MA
- Boston University School of Public Health, Boston, MA
| | - Hanife Saglam
- Department of Neurology, Brigham & Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Meghan R Hutch
- Department of Neurology, Brigham & Women's Hospital, Boston, MA
| | - Min Shin
- University of North Carolina at Charlotte, Charlotte, NC
| | - Sahar F Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emelia J Benjamin
- Department of Neurology, Boston University School of Medicine, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Stelios M Smirnakis
- Department of Neurology, Brigham & Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Jamaica Plain Veterans Administration Medical Center, Boston, MA
| | - Josée Dupuis
- Boston University School of Public Health, Boston, MA
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
| | - Charlene J Ong
- Department of Neurology, Boston University School of Medicine, Boston, MA
- Department of Neurology, Boston Medical Center, Boston, MA
- Department of Neurology, Brigham & Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Burlingham CS, Mirbagheri S, Heeger DJ. A unified model of the task-evoked pupil response. SCIENCE ADVANCES 2022; 8:eabi9979. [PMID: 35442730 PMCID: PMC9020670 DOI: 10.1126/sciadv.abi9979] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 03/04/2022] [Indexed: 06/14/2023]
Abstract
The pupil dilates and reconstricts following task events. It is popular to model this task-evoked pupil response as a linear transformation of event-locked impulses, whose amplitudes are used as estimates of arousal. We show that this model is incorrect and propose an alternative model based on the physiological finding that a common neural input drives saccades and pupil size. The estimates of arousal from our model agreed with key predictions: Arousal scaled with task difficulty and behavioral performance but was invariant to small differences in trial duration. Moreover, the model offers a unified explanation for a wide range of phenomena: entrainment of pupil size and saccades to task timing, modulation of pupil response amplitude and noise with task difficulty, reaction time-dependent modulation of pupil response timing and amplitude, a constrictory pupil response time-locked to saccades, and task-dependent distortion of this saccade-locked pupil response.
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Affiliation(s)
| | - Saghar Mirbagheri
- Graduate Program in Neuroscience, University of Washington, Seattle, WA 98195, USA
| | - David J. Heeger
- Department of Psychology, New York University, New York, NY 10003, USA
- Center for Neural Science, New York University, New York, NY 10003, USA
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Lin Y, Xiao Y, Wang L, Guo Y, Zhu W, Dalip B, Kamarthi S, Schreiber KL, Edwards RR, Urman RD. Experimental Exploration of Objective Human Pain Assessment Using Multimodal Sensing Signals. Front Neurosci 2022; 16:831627. [PMID: 35221908 PMCID: PMC8874020 DOI: 10.3389/fnins.2022.831627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/07/2022] [Indexed: 11/17/2022] Open
Abstract
Optimization of pain assessment and treatment is an active area of research in healthcare. The purpose of this research is to create an objective pain intensity estimation system based on multimodal sensing signals through experimental studies. Twenty eight healthy subjects were recruited at Northeastern University. Nine physiological modalities were utilized in this research, namely facial expressions (FE), electroencephalography (EEG), eye movement (EM), skin conductance (SC), and blood volume pulse (BVP), electromyography (EMG), respiration rate (RR), skin temperature (ST), blood pressure (BP). Statistical analysis and machine learning algorithms were deployed to analyze the physiological data. FE, EEG, SC, BVP, and BP proved to be able to detect different pain states from healthy subjects. Multi-modalities proved to be promising in detecting different levels of painful states. A decision-level multi-modal fusion also proved to be efficient and accurate in classifying painful states.
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Affiliation(s)
- Yingzi Lin
- Intelligent Human Machine Systems Laboratory, College of Engineering, Northeastern University, Boston, MA, United States
- *Correspondence: Yingzi Lin,
| | - Yan Xiao
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, United States
| | - Li Wang
- Intelligent Human Machine Systems Laboratory, College of Engineering, Northeastern University, Boston, MA, United States
| | - Yikang Guo
- Intelligent Human Machine Systems Laboratory, College of Engineering, Northeastern University, Boston, MA, United States
| | - Wenchao Zhu
- Intelligent Human Machine Systems Laboratory, College of Engineering, Northeastern University, Boston, MA, United States
| | - Biren Dalip
- Intelligent Human Machine Systems Laboratory, College of Engineering, Northeastern University, Boston, MA, United States
| | - Sagar Kamarthi
- Intelligent Human Machine Systems Laboratory, College of Engineering, Northeastern University, Boston, MA, United States
| | - Kristin L. Schreiber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, United States
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, United States
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard University, Boston, MA, United States
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Zhou XL, Xing LJ, Liu HR, Qian Y, Zhu J, Xie H. Pupil Diameter Changes after Anesthesia with Different Doses of Sufentanil under Ultrasound Monitoring. Int J Clin Pract 2022; 2022:6320973. [PMID: 35910068 PMCID: PMC9303082 DOI: 10.1155/2022/6320973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/15/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This study aims to observe the changes in pupil diameter (PD) after anesthesia with different doses of sufentanil with the ultrasound method and observe whether pupil contraction is correlated with hemodynamic changes and bispectral index (BIS) values. METHODS A total of 124 patients between the ages of 18-65 with ASA I-II undergoing general anesthesia for surgery were enrolled in the study. According to the sufentanil dose initially injected, they were randomly divided into groups P, S1, S2, and S3, with 31 cases in each group. Group P was injected with normal saline. Group S1 was injected with 0.2 μg/kg of sufentanil. Group S2 was injected with 0.4 μg/kg of sufentanil. Group S3 was injected with 0.6 μg/kg of sufentanil. Following propofol administration and eye closure, the pupil diameter (PD) of the patients in the four groups was observed and measured by ultrasound after the loss of consciousness (T1) and within 3 min after the sufentanil injection at an interval of 30 s (30 s (T2), 1 min (T3), 1 min 30 s (T4), 2 min (T5), 2 min 30 s (T6), and 3 min (T7)). PD, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and BIS values at T1-T7 were recorded. RESULTS The ultrasonic method was used to observe that different doses of sufentanil could make the patients' pupils contract. During anesthesia induction, the changes in PD have a positive correlation with SBP, DBP, HR, and BIS values. CONCLUSION Ultrasound can become a new noninvasive method to monitor pupil changes during general anesthesia, and ultrasonic observation of pupil changes has great potential for individualized analgesia management in the perioperative period.
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Affiliation(s)
- Xue-Lan Zhou
- Department of Anesthesia, The Second Affiliated Hospital of Soochow University, Suzhou 215026, China
| | - Li-Ji Xing
- Department of Anesthesia, The Second Affiliated Hospital of Soochow University, Suzhou 215026, China
| | - Hai-Rui Liu
- Department of Anesthesia, The Second Affiliated Hospital of Soochow University, Suzhou 215026, China
| | - Yu Qian
- Department of Anesthesia, The Second Affiliated Hospital of Soochow University, Suzhou 215026, China
| | - Jiang Zhu
- Department of Anesthesia, The Second Affiliated Hospital of Soochow University, Suzhou 215026, China
| | - Hong Xie
- Department of Anesthesia, The Second Affiliated Hospital of Soochow University, Suzhou 215026, China
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Elyn A, Saffon N, Larson M. Monitoring the depth of palliative sedation by video-pupillometry: A case report. Palliat Med 2021; 35:2024-2027. [PMID: 34472989 DOI: 10.1177/02692163211042770] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative sedation is sometimes interrupted by undesired arousals. Pupillometry has been used in anesthesiology to monitor pain and sedation but has never been used during palliative sedation. ACTUAL CASE A 48 years-old patient, with multi-metastatic cancer, underwent palliative sedation to manage global suffering. On the second day, the patient experienced arousal which required medication adjustments to ensure pain relief and increased sedation. POSSIBLE COURSE OF ACTION Depth of sedation is monitored with clinical scales, such as the Richmond Agitation-Sedation Scale. But these scales do not measure brain stem activity and are poor at predicting arousal. FORMULATION OF A PLAN During palliative sedation, an infrared pupillometer was used to monitor pupil size and pupillary reactivity (Neurolight®, IDMed®, Marseille, France). OUTCOME The pupillary light reflex was depressed during deep sedation. In our case, we observed a low-normal reflex along with dilated pupil before arousal. LESSONS FROM THE CASE Our case suggests that reflex intensity and pupil size might predict arousals during palliative sedation. VIEW ON RESEARCH PROBLEMS, OBJECTIVES, OR QUESTIONS GENERATED BY THE CASE Prospective studies are needed to confirm our findings. Pupillometry's acceptability should also be questioned from patient's, families', and caregivers' perspectives.
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Affiliation(s)
- Antoine Elyn
- Chronic Pain Unit, Neuroscience Department, University Hospital of Toulouse, Toulouse, France
| | - Nicolas Saffon
- Palliative Care Unit, Geriatrics and Internal Medicine Department, University Hospital of Toulouse, Toulouse, France
| | - Merlin Larson
- Anesthesia and Peri-Operative Care, University of California, San Francisco, CA, USA
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11
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Detection of opioid effect with pupillometry. Auton Neurosci 2021; 235:102869. [PMID: 34474355 DOI: 10.1016/j.autneu.2021.102869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/16/2021] [Accepted: 08/12/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Opioids produce pupillary constriction but their impact on pupillary unrest and the dynamic parameters of the pupillary light reflex have not been characterized. Given the increasing use of portable pupillometers for care of critically ill patients, it is important to distinguish between opioid effects on the pupil versus those that have been reported to arise from traumatic and ischemic brain insults. We undertook this study to determine which pupillary responses are most profoundly and consistently affected by a progressive infusion of remifentanil. METHODS We studied the effect of remifentanil on the pupil using two portable infrared pupillometers in 18 volunteers. One pupillometer measured pupillary unrest in ambient light (PUAL) and the other pupillometer measured neurological pupillary index (NPi), constriction velocity (CV), pupil diameter (PD), latency, and % reflex (% reflex) following a transient light flash. Remifentanil was administered at predetermined weight-adjusted rates to raise opioid effect site concentration up to a range known to produce respiratory depression and oxyhemoglobin desaturation, based on a previously published pharmacokinetic model. RESULTS PUAL was ablated by remifentanil, declining 94 ± 6% from baseline at the time of maximum drug effect. Other pupillary measurements decreased 50-65% from baseline. NPi was unchanged. At the time of oxyhemoglobin desaturation, deviations in PD, CV, and % reflex were widely scattered, whereas PUAL consistently approached zero. CONCLUSION PUAL is a highly specific indicator of central opioid effect. As a non-invasive measure, it may provide useful data to clinicians who prescribe opioids.
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An experimental study of objective pain measurement using pupillary response based on genetic algorithm and artificial neural network. APPL INTELL 2021. [DOI: 10.1007/s10489-021-02458-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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13
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Pupillary unrest, opioid intensity, and the impact of environmental stimulation on respiratory depression. J Clin Monit Comput 2021; 36:473-482. [PMID: 33651243 PMCID: PMC9123055 DOI: 10.1007/s10877-021-00675-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 02/12/2021] [Indexed: 11/24/2022]
Abstract
Opioid-induced respiratory depression (OIRD) confers significant morbidity, but its onset can be challenging to recognize. Pain or stimulation effects of conversation may mask or attenuate common clinical manifestations of OIRD. We asked whether pupillary unrest could provide an objective signal of opioid exposure, and whether this signal would be independent from the confounding influence of extrinsic stimulation. We conducted a cross-over trial of healthy volunteers using identical remifentanil infusions separated by a washout period; in both, pupillary unrest in ambient light (PUAL) was measured at 2.5-min intervals. During one infusion, investigators continuously engaged the subject in conversation, while in the other, a quiet environment was maintained; measures of respiratory depression were compared under each condition. We tested PUAL’s relationship to estimated opioid concentration under quiet conditions, measured PUAL’s discrimination of lower versus higher opioid exposure using receiver operating characteristic (ROC) analysis, and assessed the effect of stimulation on PUAL versus opioid using mixed effects regression. Respiratory depression occurred more frequently under quiet conditions (p < 0.0001). Under both conditions, PUAL declined significantly over the course of the remifentanil infusion and rose during recovery (p < 0.0001). PUAL showed excellent discrimination in distinguishing higher versus absent-moderate opioid exposure (AUROC = 0.957 [0.929 to 0.985]), but was unaffected by interactive versus quiet conditions (mean difference, interactive – quiet = − 0.007, 95% CI − 0.016 to 0.002). PUAL is a consistent indicator of opioid effect, and distinguishes higher opioid concentrations independently of the stimulating effects of conversational interaction. Under equivalent opioid exposure, conversational interaction delayed the onset and minimized the severity of OIRD. Clinical trial registration: NCT 04301895
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Packiasabapathy S, Rangasamy V, Sadhasivam S. Pupillometry in perioperative medicine: a narrative review. Can J Anaesth 2021; 68:566-578. [PMID: 33432497 DOI: 10.1007/s12630-020-01905-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 11/07/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Pupillometry is a technique for objective quantification of nociception that takes into account the central processing of noxious stimuli and its sympathetic response. This narrative review provides an overview of the physiology of the pupil, the principles of pupillometry, and its potential application in the perioperative environment, especially in nociception monitoring and quantifying responses to opioids. SOURCE Relevant articles, including reports of original investigation, review articles, and meta-analyses were identified from searches of PubMed and Google Scholar databases. Articles that described pupillary physiology and pupillometry, along with original research reports of the application of pupillometry in perioperative and critical care environment were used to synthesize a narrative review. PRINCIPAL FINDINGS Pupillometry is emerging as an objective measure of nociception, especially in patients under general anesthesia, children, non-verbal patients, and critically ill patients who cannot effectively communicate ongoing pain. Portable automated pupillometers have made accurate quantification of pupillary reflexes, including light reflex and dilatation reflex, possible. This technique has been successfully studied in the perioperative setting for a number of applications, including quantification of nociception, response to analgesia, and assessing efficacy of regional blocks. Pupillary oscillations have shown promise in assessing central opioid effects. Pupillometers can also accurately quantify light reflexes during the neurologic evaluation of critically ill patients. CONCLUSIONS Pupillometry is an easy to use non-invasive bedside technique to quantify nociception and monitor opioid effects. It has the potential to personalize pain management in perioperative and intensive care unit environments. Additional studies are needed to further understand the utility of pupillometry in this context.
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Affiliation(s)
- Senthil Packiasabapathy
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, RH 2835, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Valluvan Rangasamy
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, RH 2835, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Senthilkumar Sadhasivam
- Department of Anesthesia, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, RH 2835, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA.
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15
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Feasibility study of a smartphone pupillometer and evaluation of its accuracy. J Clin Monit Comput 2020; 35:1269-1277. [PMID: 32951188 DOI: 10.1007/s10877-020-00592-x] [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: 06/11/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
Measurement of pupillary characteristics, such as pupillary unrest in ambient light, and reflex dilation have been shown to be useful in a variety of clinical situations. Dedicated pupillometers typically capture images in the near-infrared to allow imaging in both light and darkness. However, because a subset of pupillary measurements can be acquired with levels of visible light suitable for conventional cameras, it is theoretically possible to capture data using general purpose cameras and computing devices such as those found on smartphones. Here we describe the development of a smartphone-based pupillometer and compare its performance with a commercial pupillometer. Smartphone pupillometry software was developed and then compared with a commercial pupillometer by performing simultaneous scans in both eyes, using the smartphone pupillometer and a commercial pupillometer. The raw scans were compared, as well as a selected pupillary index: pupillary unrest in ambient light. In 77% of the scans the software was able to successfully identify the pupil and iris. The raw data as well as calculated values of pupillary unrest in ambient light were in clinically acceptable levels of agreement; Bland-Altman analysis of raw pupil measurements yielded a 95% confidence interval of 0.26 mm. In certain situations a smartphone pupillometer may be an appropriate alternative to a commercial pupillometer.
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Charier D, Vogler MC, Zantour D, Pichot V, Martins-Baltar A, Courbon M, Roche F, Vassal F, Molliex S. Assessing pain in the postoperative period: Analgesia Nociception Index TMversus pupillometry. Br J Anaesth 2019; 123:e322-e327. [PMID: 30915996 DOI: 10.1016/j.bja.2018.09.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 08/29/2018] [Accepted: 09/24/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Potential methods for objective assessment of postoperative pain include the Analgesia Nociception Index™ (ANI), a real-time index of the parasympathetic tone, the pupillary light reflex (PLR), and the variation coefficient of pupillary diameter (VCPD), a measure of pupillary diameter (PD) fluctuations. Until now, the literature is divided as to their respective accuracy magnitudes for assessing a patient's pain. The VCPD has been demonstrated to strongly correlate with pain in an obstetrical population. However, the pain induced by obstetrical labour is different, given its intermittent nature, than the pain observed during the postoperative period. The aim of the current study was to compare the respective values of these variables at VAS scores ≥4. METHODS After approval by the Ethics Committee, 345 patients aged on average 50 (SD 17) yr (range: 18-91 yr) of age were included. The protocols of general anaesthesia and postoperative analgesia were left to the anaesthetist's discretion. Some 40 min after tracheal intubation, VAS, ANI, PD, PLR, and VCPD values were recorded. RESULTS VCPD correlates more strongly (r=0.78) with pain as assessed with the VAS than ANI (r=-0.15). PD and PLR are not statistically correlated with VAS. The ability of VCPD to assess the pain of patients (VAS≥4) is strong [area under the curve (AUC): 0.92, confidence interval (CI): 0.89-0.95], and better than for ANI (AUC: 0.39, CI: 0.33-0.45). CONCLUSIONS Our study suggests that VCPD could be a useful tool for monitoring pain in conscious patients during the postoperative period. CLINICAL TRIAL REGISTRATION NCT03267979.
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Affiliation(s)
- David Charier
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Saint-Etienne, France; Research Team EA 4607, SNA-EPIS, Jean Monnet University, Saint-Etienne, France.
| | - Marie-Charlotte Vogler
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Saint-Etienne, France
| | - Daniel Zantour
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Saint-Etienne, France
| | - Vincent Pichot
- Clinical Physiology and Exercise Department, University Hospital, Saint-Etienne, France; Research Team EA 4607, SNA-EPIS, Jean Monnet University, Saint-Etienne, France
| | | | - Marjolaine Courbon
- Jacques Lisfranc Faculty of Medicine, Jean Monnet University, Saint-Etienne, France
| | - Frédéric Roche
- Clinical Physiology and Exercise Department, University Hospital, Saint-Etienne, France; Research Team EA 4607, SNA-EPIS, Jean Monnet University, Saint-Etienne, France
| | - François Vassal
- Neurosurgery, University Hospital, Saint-Etienne, France; INSERM U1028, Central Integration of Pain Lab, Jean Monnet University, Saint-Etienne, France
| | - Serge Molliex
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Saint-Etienne, France; Research Team EA 4607, SNA-EPIS, Jean Monnet University, Saint-Etienne, France
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Behrends M, Larson MD, Neice AE, Bokoch MP. Suppression of pupillary unrest by general anesthesia and propofol sedation. J Clin Monit Comput 2018; 33:317-323. [DOI: 10.1007/s10877-018-0147-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 04/23/2018] [Indexed: 11/27/2022]
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18
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McKay RE, Neice AE, Larson MD. Pupillary Unrest in Ambient Light and Prediction of Opioid Responsiveness: Case Report on Its Utility in the Management of 2 Patients With Challenging Acute Pain Conditions. A A Pract 2018; 10:279-282. [PMID: 29608463 DOI: 10.1213/xaa.0000000000000710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Pupillary unrest in ambient light (PUAL), the normal pattern of pupil diameter fluctuation present in awake humans, has been proposed as a marker of central opioid effect. We report 2 cases in which PUAL identified the appropriate pain management for 2 patients, each with unique, challenging acute pain conditions. In both cases, PUAL accurately predicted opioid responsiveness, suggesting an effective, individualized analgesic approach for both patients.
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Affiliation(s)
- Rachel Eshima McKay
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Andrew E Neice
- Department of Anesthesiology and Perioperative Medicine, Oregon Health Sciences University, Portland, Oregon
| | - Merlin D Larson
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
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19
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Neice AE. Pupil Size Variation and Pain-Can the Results be Generalized? THE JOURNAL OF PAIN 2018; 19:569. [PMID: 29706354 DOI: 10.1016/j.jpain.2017.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 10/14/2017] [Accepted: 12/05/2017] [Indexed: 10/17/2022]
Affiliation(s)
- Andrew E Neice
- Department of Anesthesia, Oregon Health and Science University, Portland, Oregon.
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20
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Neice AE, Larson MD, Behrends M, Bokoch MP. In Response. Anesth Analg 2017. [DOI: 10.1213/ane.0000000000002213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Neice AE, Behrends M, Bokoch MP, Seligman KM, Conrad NM, Larson MD. Prediction of Opioid Analgesic Efficacy by Measurement of Pupillary Unrest. Anesth Analg 2017; 124:915-921. [PMID: 27941575 DOI: 10.1213/ane.0000000000001728] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pupillary unrest under ambient light (PUAL) is the fluctuation in pupil diameter in time around a mean value. PUAL is augmented by light and diminished by administration of opioids. We hypothesized that, because pupillary unrest is a marker of opioid effect, low levels of PUAL may be associated with reduced opioid efficacy, as measured by changes in the numerical rating scale (NRS) pain scores of patients in the postanesthesia care unit (PACU). METHODS We used an infrared pupillometer to measure PUAL in patients recovering from ambulatory surgery at 2 different institutions. At both sites, PUAL was quantified using spectral analysis of the Fourier transform of pupil diameter versus time. We measured PUAL and pain scores before and after opioid administration. Protocols for total capture time and lighting conditions varied between the 2 sites. Correlations between PUAL and change in NRS scores were examined using significance testing of Pearson correlation coefficients. Correlations between change in PUAL and change in NRS scores were also examined. Patients were divided into high and low PUAL groups, and high and low response to opioid. A Fisher exact test was used to determine whether there was a significant association between PUAL and opioid response. RESULTS For patients with pain in the PACU, low levels of pupillary unrest before opioid therapy were associated with minimal or no reduction in pain scores after opioid administration. We noted a significant correlation at both sites between PUAL and pain score reduction with opioids (r = 0.59, P = .0053, and r = 0.57, P = .022.) The Fisher exact test confirmed that patients with PUAL levels above the mean had a more beneficial analgesic effect from opioids than those with low PUAL levels (P = .018). We also noted that change in PUAL was significantly correlated with change in pain score at both sites (r = 0.56, P = .03 and r = 0.55, P = .01). CONCLUSIONS We observe that the pretreatment magnitude of PUAL is correlated with the analgesic response to opioid therapy, and that patients who exhibit higher levels of PUAL change after opioid administration have a more beneficial analgesic effect from opioids. Larger studies with uniform measurement protocols are required to confirm these preliminary results.
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Affiliation(s)
- Andrew E Neice
- From the *Department of Anesthesia, Oregon Health and Science University, Portland, Oregon; †Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; ‡Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico; and §Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
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22
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Charier DJ, Zantour D, Pichot V, Chouchou F, Barthelemy JCM, Roche F, Molliex SB. Assessing Pain Using the Variation Coefficient of Pupillary Diameter. THE JOURNAL OF PAIN 2017; 18:1346-1353. [PMID: 28711635 DOI: 10.1016/j.jpain.2017.06.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 06/21/2017] [Accepted: 06/24/2017] [Indexed: 11/19/2022]
Abstract
Pupillary diameter (PD) varies under the influence of the sympathetic as well as parasympathetic systems, increasing proportionally with pain intensity. Such variations however, should not be confused with pupillary fluctuations, which refer to the fast and permanent PD fluctuations induced by the ongoing interplay between the sympathetic and parasympathetic systems, which we propose to measure using the variation coefficient of PD (VCPD). This study aimed first at correlating PD, PD increase during a contraction, and VCPD, with pain rated using a numeric rating scale (NRS) during obstetrical labor, and then at comparing such correlations with each other. Forty patients were included in the study, and 160 simultaneous ratings (NRS, PD, and VCPD) were taken: 40 in the presence of uterine contractions and 40 in the absence of such contractions, before and 20 minutes after epidural analgesia. VCPD correlates more strongly (r = .77) than PD increase (r = .42) with pain rated using a NRS. The ability of VCPD to predict the occurrence of NRS scores ≥4 during obstetrical labor is .97 (confidence interval, .93-1.0). When measured over 10 seconds during contraction, VCPD correlates more strongly than PD increase with pain rated using the NRS. Such stronger correlation allows for an easy assessment of antinociception-nociception balance. PERSPECTIVE The VCPD allows for an objective assessment of pain in laboring women. It could allow for an easy assessment of pain in noncommunicating patients: newborns or very old patients, patients with serious psychological conditions, assessment during the immediate postoperative period, or in intensive care units.
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Affiliation(s)
- David J Charier
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Saint-Etienne, France; Jean Monnet University Research Team EA 4607, SNA-EPIS, Saint-Etienne, France.
| | - Daniel Zantour
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Saint-Etienne, France
| | - Vincent Pichot
- Jean Monnet University Research Team EA 4607, SNA-EPIS, Saint-Etienne, France; Clinical Physiology and Exercise Department, University Hospital, Saint-Etienne, France
| | - Florian Chouchou
- NeuroPain, Central Integration of Pain in Humans, Lyon Neuroscience Research Center, Inserm U1028, CNRS UMR 5292, Lyon, France
| | - Jean-Claude M Barthelemy
- Jean Monnet University Research Team EA 4607, SNA-EPIS, Saint-Etienne, France; Clinical Physiology and Exercise Department, University Hospital, Saint-Etienne, France
| | - Frederic Roche
- Jean Monnet University Research Team EA 4607, SNA-EPIS, Saint-Etienne, France; Clinical Physiology and Exercise Department, University Hospital, Saint-Etienne, France
| | - Serge B Molliex
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Saint-Etienne, France; Jean Monnet University Research Team EA 4607, SNA-EPIS, Saint-Etienne, France
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Abstract
This paper is the thirty-eighth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2015 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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24
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Larson MD, Singh V. Portable infrared pupillometry in critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:161. [PMID: 27329287 PMCID: PMC4916536 DOI: 10.1186/s13054-016-1349-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Infrared pupillometry was introduced in 1962 but portable instruments that use this technology have only recently become available in the hospital setting. Questions surrounding the accuracy of these instruments have been addressed by documenting the inter-observer agreement on pupillary measurements and also by comparisons with standard pen-light examinations. The following commentary summarizes the development of these devices and provides a wider perspective on how the pupil and its reflexes might be used in providing care for patients with critical illness.
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Affiliation(s)
- Merlin D Larson
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, 94143, USA. .,Departments of Anesthesiology and Neurology, University of California, San Francisco, CA, 94143-0648, USA.
| | - Vineeta Singh
- Department of Neurology, University of California, San Francisco, CA, 94143, USA
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Jochum T, Hoyme J, Schulz S, Weißenfels M, Voss A, Bär KJ. Diverse autonomic regulation of pupillary function and the cardiovascular system during alcohol withdrawal. Drug Alcohol Depend 2016; 159:142-51. [PMID: 26790823 DOI: 10.1016/j.drugalcdep.2015.12.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous research indicated the complexity of autonomic dysfunction during acute alcohol withdrawal. This study aimed to investigate the pupillary light reflex as an indicator of midbrain and brainstem regulatory systems in relation to cardiovascular autonomic function. METHODS Thirty male patients were included in the study. They were investigated during acute alcohol withdrawal syndrome and 24h later during clomethiazole treatment and compared to healthy controls. Parameters of pupillary light reflex of both eyes as well as heart rate variability, blood pressure variability and baroreflex sensitivity (BRS) were studied. RESULTS We observed significantly reduced sympathetic (small diameter, e.g., left eye: 5.00 in patients vs. 5.91 mm in controls) and vagal modulation (e.g., prolonged latencies, left eye: 0.28 vs. 0.26 ms) regarding both pupils during acute alcohol withdrawal syndrome. Cardiovascular parameters showed reduced vagal modulation (e.g., b-slope of BRS: 7. 57 vs. 13.59 ms/mm Hg) and mixed results for sympathetic influence. After 24h, autonomic dysfunction improved significantly, both for the pupils (e.g., left diameter: 5.38 mm) and the heart (e.g., b-slope of BRS: 9.34 ms/mm Hg). While parameters obtained from the pupil correlated with cardiac autonomic function (e.g, BRS and left diameter: r=0.564) in healthy controls, no such pattern was observed in patients. CONCLUSION Results obtained from the pupil during acute alcohol withdrawal do not simply mirror autonomic dysfunction regarding the heart. Pupillary and cardiovascular changes after 24h indicate state dependencies of the results. The findings are discussed with respect to autonomic mechanisms and potentially involved brain regions.
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Affiliation(s)
- Thomas Jochum
- Psychiatric Brain & Body Research Group Jena, Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany
| | - Johannes Hoyme
- Psychiatric Brain & Body Research Group Jena, Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany
| | - Steffen Schulz
- Department of Medical Engineering and Biotechnology, Ernst-Abbe-Hochschule Jena, University of Applied Sciences, Jena, Germany
| | - Markus Weißenfels
- Psychiatric Brain & Body Research Group Jena, Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany
| | - Andreas Voss
- Department of Medical Engineering and Biotechnology, Ernst-Abbe-Hochschule Jena, University of Applied Sciences, Jena, Germany
| | - Karl-Jürgen Bär
- Psychiatric Brain & Body Research Group Jena, Department of Psychiatry and Psychotherapy, Jena University Hospital, Jena, Germany.
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Joshi S, Li Y, Kalwani RM, Gold JI. Relationships between Pupil Diameter and Neuronal Activity in the Locus Coeruleus, Colliculi, and Cingulate Cortex. Neuron 2015; 89:221-34. [PMID: 26711118 DOI: 10.1016/j.neuron.2015.11.028] [Citation(s) in RCA: 761] [Impact Index Per Article: 84.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/25/2015] [Accepted: 11/11/2015] [Indexed: 11/25/2022]
Abstract
Changes in pupil diameter that reflect effort and other cognitive factors are often interpreted in terms of the activity of norepinephrine-containing neurons in the brainstem nucleus locus coeruleus (LC), but there is little direct evidence for such a relationship. Here, we show that LC activation reliably anticipates changes in pupil diameter that either fluctuate naturally or are driven by external events during near fixation, as in many psychophysical tasks. This relationship occurs on as fine a temporal and spatial scale as single spikes from single units. However, this relationship is not specific to the LC. Similar relationships, albeit with delayed timing and different reliabilities across sites, are evident in the inferior and superior colliculus and anterior and posterior cingulate cortex. Because these regions are interconnected with the LC, the results suggest that non-luminance-mediated changes in pupil diameter might reflect LC-mediated coordination of neuronal activity throughout some parts of the brain.
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Affiliation(s)
- Siddhartha Joshi
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Yin Li
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rishi M Kalwani
- Temple University School of Medicine, Philadelphia, PA 19140, USA
| | - Joshua I Gold
- Department of Neuroscience, University of Pennsylvania, Philadelphia, PA 19104, USA
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