1
|
Mascaró Triedo CE, Karar S, Abunemeh M, Portier K. Effect of nose twitching on the pupillary dilation in awake and anesthetized horses. Front Vet Sci 2024; 11:1412755. [PMID: 39036796 PMCID: PMC11258756 DOI: 10.3389/fvets.2024.1412755] [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: 04/05/2024] [Accepted: 06/26/2024] [Indexed: 07/23/2024] Open
Abstract
Pupillometry is used in humans to monitor pain, nociception and analgesia. This single-center, non-randomized, non-blinded intervention trial, evaluated the effect of nose twitching on the pupil size in awake, sedated, and anesthetized horses. Pupil height (H) and length (L) were measured before (Be) and after (Af) nose twitching in fourteen non-painful adult awake horses (T0). The percentage of variation (PSV) was calculated (PSVTn = [(TnAf-TnBe)/TnBe]*100). Measurements were repeated (Tn) after acepromazine (0.04 mg kg-1 IV) (T1), romifidine (0.04 mg kg-1 IV) (T2), morphine (0.1 mg kg-1 IV) (T3), after anesthesia induction with diazepam (0.05 mg kg-1 IV) and ketamine (2.2 mg kg-1 IV), at the time the horse was placed on the operating table (T4) and when the expiratory fraction of sevoflurane was 2% (T5). HAf vs. HBe, LAf vs. LBe as well as PSVH vs. PSVL at each time were compared with a Mann-Whitney Wilcoxon test. The PSVL and PSVH, as well as HBe and LBe over time were compared with the Skillings-Mack test followed by a Wilcoxon test for paired data to make pairwise comparisons (Tn + 1 vs. Tn). In non-sedated horses (T0), the application of the nose twitch induced a significant increase in pupil length (LT0Be: 17.09 [16.05; 19.67] mm versus LT0Af: 19.52 [18.74; 21.40]) mm (p = 0.004). Thirty minutes after acepromazine administration (T1), nose twitching induced a significant increase in pupil length (LT1Be: 16.45 [14.80; 18.66] mm versus LT1Af 18.31 [17.20; 20.52] mm) (p = 0.016) and height (HT1Be: 8.44 [5.68; 12.04] mm versus HT1Af: 11.09 [7.97; 14.3] mm) (p < 0.001). PSVHT1 was significantly greater than PSVLT1 (p = 0.025). PSVH was higher at T1 than at T0 (p = 0.04). It was also significantly higher at T1 than at T2 (p < 0.001). Romifidine induced mydriasis (HT2Be 16.95 [14.73; 18.77] mm versus HT1Be 8.44 [5.68; 12.04] mm) (p < 0,001) (LT2Be 19.66 [18.45; 20.41] mm versus LT1Be 16.45 [14.80; 18.66] mm) (p < 0.001). The results suggest that nose twitching induced a pupillary dilation in the awake horse. This effect was potentiated after the administration of acepromazine but disappeared after the administration of romifidine.
Collapse
Affiliation(s)
| | - Sahra Karar
- VetAgro Sup, CREFAC, Université de Lyon, Marcy l’Etoile, France
| | - Maha Abunemeh
- VetAgro Sup, CREFAC, Université de Lyon, Marcy l’Etoile, France
| | - Karine Portier
- VetAgro Sup, CREFAC, Université de Lyon, Marcy l’Etoile, France
- Centre de Recherche en Neurosciences de Lyon, INSERM, CRNL U1028 UMR5292, Trajectoire, Université Claude Bernard Lyon 1, Bron, France
| |
Collapse
|
2
|
Shi L, Jin DN, Cao XJ, Liu H, Gu WJ, Zhang M, Lu Q. Assessment of sedation by automated pupillometry in critically ill patients: a prospective observational study. Br J Anaesth 2024; 132:877-885. [PMID: 38429209 DOI: 10.1016/j.bja.2024.02.001] [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: 09/11/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Quantitative measurement of pupil change has not been assessed against the Richmond Agitation and Sedation Scale (RASS) and spectral edge frequency (SEF) during sedation. The aim of this study was to evaluate pupillometry against these measures in sedated critically ill adult patients. METHODS In ventilated and sedated patients, pupillary variables were measured by automated pupillometry at each RASS level from -5 to 0 after discontinuation of hypnotics, while processed electroencephalogram variables were displayed continuously and SEF was recorded at each RASS level. Correlations were made between percentage pupillary light reflex (%PLR) and RASS, and between %PLR and SEF. The ability of %PLR to differentiate light sedation (RASS ≥-2), moderate (RASS =-3), and deep sedation (RASS ≤-4) was assessed by areas under receiver operating characteristic (ROC) curves. RESULTS A total of 163 paired measurements were recorded in 38 patients. With decreasing sedation depth, median %PLR increased progressively from 20% (interquartile range 17-25%) to 36% (interquartile range 33-40%) (P<0.001). Strong correlations were found between %PLR and RASS (Rho=0.635) and between %PLR and SEF (R=0.641). Area under the curve (AUC) of 0.87 with a %PLR threshold of 28% differentiated moderate/light sedation from deep sedation with sensitivity of 83% and specificity of 83%. An AUC of 0.82 with a threshold of 31% distinguished light sedation from moderate/deep sedation with a sensitivity of 81% and a specificity of 75%. CONCLUSIONS Quantitative assessment of %PLR correlates with other indicators of sedation depth in critically ill patients.
Collapse
Affiliation(s)
- Lin Shi
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Emergency Department, The State Key Laboratory for Complex, Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Dan-Ni Jin
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Xia-Jing Cao
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Hong Liu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Wen-Jie Gu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China.
| | - Qin Lu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, Zhejiang, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, Zhejiang, China.
| |
Collapse
|
3
|
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).
Collapse
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.
| |
Collapse
|
4
|
Salpeter EM, Moshiri A, Ferneding M, Motta MJ, Park S, Skouritakis C, Thomasy SM. Chromatic Pupillometry as a Putative Screening Tool for Heritable Retinal Disease in Rhesus Macaques. Transl Vis Sci Technol 2023; 12:13. [PMID: 38752621 PMCID: PMC10289275 DOI: 10.1167/tvst.12.6.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/22/2023] [Indexed: 05/19/2024] Open
Abstract
Purpose Non-human primates (NHPs) are useful models for human retinal disease. Chromatic pupillometry has been proposed as a noninvasive method of identifying inherited retinal diseases (IRDs) in humans; however, standard protocols employ time-consuming dark adaptation. We utilized shortened and standard dark-adaptation protocols to compare pupillary light reflex characteristics following chromatic stimulation in rhesus macaques with achromatopsia to wild-type (WT) controls with normal retinal function. Methods Nine rhesus macaques homozygous for the p.R656Q mutation (PDE6C HOMs) and nine WT controls were evaluated using chromatic pupillometry following 1-minute versus standard 20-minute dark adaptations. The following outcomes were measured and compared between groups: pupil constriction latency, peak constriction, pupil constriction time, and constriction velocity. Results Pupil constriction latency was significantly longer in PDE6C HOMs with red-light (P = 0.0002) and blue-light (P = 0.04) stimulation versus WT controls. Peak constriction was significantly less in PDE6C HOMs with all light stimulation compared to WT controls (P < 0.0001). Pupil constriction time was significantly shorter in PDE6C HOMs versus WT controls with red-light (P = 0.04) and white-light (P = 0.003) stimulation. Pupil constriction velocity was significantly slower in PDE6C HOMs versus WT controls with red-light (P < 0.0001), blue-light (P < 0.0001), and white-light (P = 0.0002) stimulation. Dark adaptation time only significantly affected peak (P = 0.008) and time of pupil constriction (P = 0.02) following blue-light stimulation. Conclusions Chromatic pupillometry following 1- and 20-minute dark adaptation is an effective tool for screening NHPs for achromatopsia. Translational Relevance Rapid identification of NHPs with IRDs will provide animal research models to advance research and treatment of achromatopia in humans.
Collapse
Affiliation(s)
- Elyse M. Salpeter
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California Davis, Davis, CA, USA
| | - Ala Moshiri
- Department of Ophthalmology and Vision Science, School of Medicine, University of California Davis, Davis, CA, USA
| | - Michelle Ferneding
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California Davis, Davis, CA, USA
| | - Monica J. Motta
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California Davis, Davis, CA, USA
| | - Sangwan Park
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California Davis, Davis, CA, USA
| | - Chrisoula Skouritakis
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California Davis, Davis, CA, USA
| | - Sara M. Thomasy
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California Davis, Davis, CA, USA
- Department of Ophthalmology and Vision Science, School of Medicine, University of California Davis, Davis, CA, USA
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Daniel M, Charier D, Pereira B, Pachcinski M, Sharshar T, Molliex S. Prognosis value of pupillometry in COVID-19 patients admitted in intensive care unit. Auton Neurosci 2023; 245:103057. [PMID: 36549090 PMCID: PMC9758063 DOI: 10.1016/j.autneu.2022.103057] [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: 07/18/2022] [Revised: 10/26/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION ICU patients with SARS-CoV-2-related pneumonia are at risk to develop a central dysautonomia which can contribute to mortality and respiratory failure. The pupillary size and its reactivity to light are controlled by the autonomic nervous system. Pupillometry parameters (PP) allow to predict outcomes in various acute brain injuries. We aim at assessing the most predictive PP of in-hospital mortality and the need for invasive mechanical ventilation (IV). MATERIAL AND METHODS We led a prospective, two centers, observational study. We recruited adult patients admitted to ICU for a severe SARS-CoV-2 related pneumonia between April and August 2020. The pupillometry was performed at admission including the measurement of baseline pupillary diameter (PD), PD variations (PDV), pupillary constriction velocity (PCV) and latency (PDL). RESULTS Fifty patients, 90 % males, aged 66 (60-70) years were included. Seven (14 %) patients died in hospital. The baseline PD (4.1 mm [3.5; 4.8] vs 2.6 mm [2.4; 4.0], P = 0.009), PDV (33 % [27; 39] vs 25 % [15; 36], P = 0.03) and PCV (3.5 mm.s-1 [2.8; 4.4] vs 2.0 mm.s-1 [1.9; 3.8], P = 0.02) were significantly lower in patients who will die. A PD value <2.75 mm was the most predictive parameter of in-hospital mortality, with an AUC = 0.81, CI 95 % [0.63; 0.99]. Twenty-four (48 %) patients required IV. PD and PDV were significantly lower in patients who were intubated (3.5 mm [2.8; 4.4] vs 4.2 mm [3.9; 5.2], P = 0.03; 28 % [25; 36 %] vs 35 % [32; 40], P = 0.049, respectively). CONCLUSIONS A reduced baseline PD is associated with bad outcomes in COVID-19 patients admitted in ICU. It is likely to reflect a brainstem autonomic dysfunction.
Collapse
Affiliation(s)
- Matthieu Daniel
- Medical and Surgical Neurointensive Care Unit, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France; University of Paris, Paris, France.
| | - David Charier
- Anesthesia and Intensive Care Department & Sainbiose INSERM Unité 1059, Université Jean Monnet, Saint-Etienne, France
| | - Bruno Pereira
- Department of Clinical Research and Innovation, CHU of Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Tarek Sharshar
- Medical and Surgical Neurointensive Care Unit, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France,Department of Infection and Epidemiology, Pasteur Institute, University of Paris, Paris, France
| | - Serge Molliex
- Anesthesia and Intensive Care Department & Sainbiose INSERM Unité 1059, Université Jean Monnet, Saint-Etienne, France
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Opic P, Rüegg S, Marsch S, Gut SS, Sutter R. Automated Quantitative Pupillometry in the Critically Ill: A Systematic Review of the Literature. Neurology 2021; 97:e629-e642. [PMID: 34045270 DOI: 10.1212/wnl.0000000000012295] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE A systematic literature search has been performed to identify potential confounders for outcome prediction using pupillary light reflex in adult critically ill patients, as measured by handheld automated pupillometry devices. METHODS Three digital databases (PubMed, EmBase, Cochrane) were systematically searched. Articles published between 1990 and 2019 in adult patients using monocular automated handheld devices were considered. Studies were classified according to the Oxford Centre for Evidence-Based Medicine classification (level 1 represents the highest and level 5 the lowest level of evidence). Case reports, original research, and systematic reviews were included and cross-referenced. RESULTS With the use of 202 search terms, 58 eligible articles reporting the use of handheld pupillometry in the critically ill could be identified, considering 3,246 patients. The highest level of evidence came from 10 randomized trials and 19 prospective observational studies. The level of evidence was mostly 2 to 3 and highest with studies regarding the potential confounding effects of pain, the use of opioids, and increased intracranial pressure. Additional potential confounders found are selective serotonin reuptake inhibitors, α2-adregenic receptor agonists, and NMDA antagonists. CONCLUSIONS The pupillary light reflex is susceptible to factors resulting from underlying comorbid conditions and effects of treatment regimens. Scenarios frequently encountered in critical care such as pain, use of opioids, and proof of increased intracranial pressure have potential confounding effects on outcome and pupillary reflexes. When treatment is guided by pupillary metrics, such confounders put patients at risk of overtreatment or undertreatment. Future research should validate and identify additional confounders, because our review suggests that even more unexplored confounders may exist.
Collapse
Affiliation(s)
- Petra Opic
- From the Department of Intensive Care (P.O., S.M., R.S.), Basel Pharmacoepidemiology Unit (S.S.G.), Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, and Hospital Pharmacy (S.S.G.), University Hospital Basel; Department of Neurology (S.R., R.S.), Department of Clinical Research, Department of Clinical Research (S.R., S.M., R.S.), Medical Faculty, and Medical Faculty (S.M., R.S.), University of Basel, Switzerland.
| | - Stephan Rüegg
- From the Department of Intensive Care (P.O., S.M., R.S.), Basel Pharmacoepidemiology Unit (S.S.G.), Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, and Hospital Pharmacy (S.S.G.), University Hospital Basel; Department of Neurology (S.R., R.S.), Department of Clinical Research, Department of Clinical Research (S.R., S.M., R.S.), Medical Faculty, and Medical Faculty (S.M., R.S.), University of Basel, Switzerland
| | - Stephan Marsch
- From the Department of Intensive Care (P.O., S.M., R.S.), Basel Pharmacoepidemiology Unit (S.S.G.), Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, and Hospital Pharmacy (S.S.G.), University Hospital Basel; Department of Neurology (S.R., R.S.), Department of Clinical Research, Department of Clinical Research (S.R., S.M., R.S.), Medical Faculty, and Medical Faculty (S.M., R.S.), University of Basel, Switzerland
| | - Stephan Sebastian Gut
- From the Department of Intensive Care (P.O., S.M., R.S.), Basel Pharmacoepidemiology Unit (S.S.G.), Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, and Hospital Pharmacy (S.S.G.), University Hospital Basel; Department of Neurology (S.R., R.S.), Department of Clinical Research, Department of Clinical Research (S.R., S.M., R.S.), Medical Faculty, and Medical Faculty (S.M., R.S.), University of Basel, Switzerland
| | - Raoul Sutter
- From the Department of Intensive Care (P.O., S.M., R.S.), Basel Pharmacoepidemiology Unit (S.S.G.), Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, and Hospital Pharmacy (S.S.G.), University Hospital Basel; Department of Neurology (S.R., R.S.), Department of Clinical Research, Department of Clinical Research (S.R., S.M., R.S.), Medical Faculty, and Medical Faculty (S.M., R.S.), University of Basel, Switzerland
| |
Collapse
|
9
|
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.
Collapse
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.
| |
Collapse
|
10
|
Oshorov AV, Alexandrova EV, Muradyan KR, Sosnovskaya OY, Sokolova EY, Savin IA. [Pupillometry as a method for monitoring of pupillary light reflex in ICU patients]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:117-123. [PMID: 34156213 DOI: 10.17116/neiro202185031117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This review is devoted to the modern method of monitoring of pupil diameter and reactivity in patients with acute brain injury. The authors present complete data on diagnostic and prognostic capabilities of automated infrared pupillometry, which should take its rightful place in comprehensive assessment of functional brain state in ICU patients. In authors' opinion, clinical introduction of pupillometry will improve prediction of outcomes following acute brain injury and quality of neurological monitoring in patients with cerebral edema and intracranial hypertension.
Collapse
Affiliation(s)
- A V Oshorov
- Burdenko Center of Neurosurgery, Moscow, Russia
| | | | | | | | | | - I A Savin
- Burdenko Center of Neurosurgery, Moscow, Russia
| |
Collapse
|
11
|
Lim BG. Nociception monitoring tools using autonomic tone changes for intraoperative analgesic guidance in pediatric patients. Anesth Pain Med (Seoul) 2019; 14:380-392. [PMID: 33329766 PMCID: PMC7713809 DOI: 10.17085/apm.2019.14.4.380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 09/30/2019] [Indexed: 12/03/2022] Open
Abstract
Nociception monitoring devices using changes in autonomic nervous system activity have been developed in numerous ways. Although there have been few studies conducted on children, compared to the relatively higher number of studies on adults, most of the nociception monitors in children, as in adults, appear to be more useful than the standard clinical practice that uses hemodynamic parameters in the evaluation and treatment of intraoperative nociception (pain) during general anesthesia. Particularly, when monitoring the surgical pleth index (SPI) in anesthetized children, the application of a new target range of SPI values (≤ 40) to the SPI monitoring criteria seems to be necessary for providing a more proper intraoperative analgesia. The analgesia nociception index (ANI) shows promising results in anesthetized adults, and recently, positive results along with cardiorespiratory coherence have been reported in pediatric patients. Newborn infant parasympathetic evaluation (NIPE) could be useful for providing adequate analgesia in newborns, infants, and children under 2 years of age in anesthetized or awake states. In cases of skin conductance and pupillometry, further studies are needed. Understanding the pros, cons, and limitations of these nociception monitoring tools will provide more effective and safe intraoperative analgesia to pediatric patients undergoing general anesthesia, and it may also help to plan and conduct promising research on the use of perioperative nociception monitoring in pediatric patients in the future.
Collapse
Affiliation(s)
- Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
12
|
Morelli P, Oddo M, Ben-Hamouda N. Role of automated pupillometry in critically ill patients. Minerva Anestesiol 2019; 85:995-1002. [DOI: 10.23736/s0375-9393.19.13437-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
13
|
Valverde A, Skelding AM. Alternatives to Opioid Analgesia in Small Animal Anesthesia: Alpha-2 Agonists. Vet Clin North Am Small Anim Pract 2019; 49:1013-1027. [PMID: 31481257 DOI: 10.1016/j.cvsm.2019.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Alpha-2 agonists have potent analgesic effects, in addition to their sedative actions. Alpha-2 agonists provide analgesia through any of several routes of administration, including parenteral, oral, epidural or intrathecal and intraarticular, because of spinal and supraspinal actions. Systemic doses are short acting, whereas local administration at the site of action result in longer analgesic effects. The potent cardiovascular and respiratory effects of alpha-2 agonists should be considered when used as analgesics.
Collapse
Affiliation(s)
- Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario N1G 2W1, Canada.
| | - Alicia M Skelding
- Toronto Animal Health Partners Emergency and Specialty Hospital, Toronto, Ontario M3B 2R2, Canada
| |
Collapse
|
14
|
|
15
|
Szabadi E. Functional Organization of the Sympathetic Pathways Controlling the Pupil: Light-Inhibited and Light-Stimulated Pathways. Front Neurol 2018; 9:1069. [PMID: 30619035 PMCID: PMC6305320 DOI: 10.3389/fneur.2018.01069] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/23/2018] [Indexed: 11/13/2022] Open
Abstract
Pupil dilation is mediated by a sympathetic output acting in opposition to parasympathetically mediated pupil constriction. While light stimulates the parasympathetic output, giving rise to the light reflex, it can both inhibit and stimulate the sympathetic output. Light-inhibited sympathetic pathways originate in retina-receptive neurones of the pretectum and the suprachiasmatic nucleus (SCN): by attenuating sympathetic activity, they allow unimpeded operation of the light reflex. Light stimulates the noradrenergic and serotonergic pathways. The hub of the noradrenergic pathway is the locus coeruleus (LC) containing both excitatory sympathetic premotor neurones (SympPN) projecting to preganglionic neurones in the spinal cord, and inhibitory parasympathetic premotor neurones (ParaPN) projecting to preganglionic neurones in the Edinger-Westphal nucleus (EWN). SympPN receive inputs from the SCN via the dorsomedial hypothalamus, orexinergic neurones of the latero-posterior hypothalamus, wake- and sleep-promoting neurones of the hypothalamus and brain stem, nociceptive collaterals of the spinothalamic tract, whereas ParaPN receive inputs from the amygdala, sleep/arousal network, nociceptive spinothalamic collaterals. The activity of LC neurones is regulated by inhibitory α2-adrenoceptors. There is a species difference in the function of the preautonomic LC. In diurnal animals, the α2-adrenoceptor agonist clonidine stimulates mainly autoreceptors on SymPN, causing miosis, whereas in nocturnal animals it stimulates postsynaptic α2-arenoceptors in the EWN, causing mydriasis. Noxious stimulation activates SympPN in diurnal animals and ParaPN in nocturnal animals, leading to pupil dilation via sympathoexcitation and parasympathetic inhibition, respectively. These differences may be attributed to increased activity of excitatory LC neurones due to stimulation by light in diurnal animals. This may also underlie the wake-promoting effect of light in diurnal animals, in contrast to its sleep-promoting effect in nocturnal species. The hub of the serotonergic pathway is the dorsal raphe nucleus that is light-sensitive, both directly and indirectly (via an orexinergic input). The light-stimulated pathways mediate a latent mydriatic effect of light on the pupil that can be unmasked by drugs that either inhibit or stimulate SympPN in these pathways. The noradrenergic pathway has widespread connections to neural networks controlling a variety of functions, such as sleep/arousal, pain, and fear/anxiety. Many physiological and psychological variables modulate pupil function via this pathway.
Collapse
Affiliation(s)
- Elemer Szabadi
- Developmental Psychiatry, Queen's Medical Centre, University of Nottingham, Nottingham, United Kingdom
| |
Collapse
|
16
|
Wildemeersch D, Gios J, Jorens PG, Hans GH. Objective Nociceptive Assessment in Ventilated ICU Patients: A Feasibility Study Using Pupillometry and the Nociceptive Flexion Reflex. J Vis Exp 2018. [PMID: 30035771 DOI: 10.3791/57972] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The concept of objective nociceptive assessment and optimal pain management have gained increasing attention. Despite the known negative short- and long-term consequences of unresolved pain or excessive analgosedation, adequate nociceptive monitoring remains challenging in non-communicative, critically ill adults. In the intensive care unit (ICU), routine nociceptive evaluation is carried out by the attending nurse using the Behavior Pain Scale (BPS) in mechanically ventilated patients. This assessment is limited by medication use (e.g., neuromuscular blocking agents) and the inherent subjective character of nociceptive evaluation by third parties. Here, we describe the use of two nociceptive reflex testing devices as tools for objective pain evaluation: the pupillary dilation reflex (PDR) and nociception flexion reflex (NFR). These measurement tools are non-invasive and well tolerated, providing clinicians and researchers with objective information regarding two different nociceptive processing pathways: (1) the pain-related autonomic reactivity and (2) the ascending component of the somatosensory system. The use of PDR and NFR measurements are currently limited to specialized pain clinics and research institutions because of impressions that these are technically demanding or time-consuming procedures, or even because of a lack of knowledge regarding their existence. By focusing on the two abovementioned nociceptive reflex assessments, this study evaluated their feasibility as a physiological pain measurement method in daily practice. Pursuing novel technologies for evaluating the analgesia level in unconscious patients may further improve individual pharmacological treatment and patient related outcome measures. Therefore, future research must include large well-designed clinical trials in a real-life environment.
Collapse
Affiliation(s)
- Davina Wildemeersch
- Multidisciplinary Pain Center, Anesthesiology and Critical Care Medicine, Antwerp University Hospital (UZA), University of Antwerp (UA);
| | - Jens Gios
- Multidisciplinary Pain Center (PCT), Antwerp University Hospital (UZA)
| | - Philippe G Jorens
- Critical Care Medicine, Antwerp University Hospital (UZA), University of Antwerp (UA)
| | - Guy H Hans
- Multidisciplinary Pain Center (PCT), Antwerp University Hospital (UZA)
| |
Collapse
|
17
|
Magnetic resonance imaging of the human locus coeruleus: A systematic review. Neurosci Biobehav Rev 2017; 83:325-355. [PMID: 29107830 DOI: 10.1016/j.neubiorev.2017.10.023] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 09/21/2017] [Accepted: 10/24/2017] [Indexed: 01/21/2023]
Abstract
The locus coeruleus (LC), the major origin of noradrenergic modulation of the central nervous system, innervates extensive areas throughout the brain and is implicated in a variety of autonomic and cognitive functions. Alterations in the LC-noradrenergic system have been associated with healthy ageing and neuropsychiatric disorders including Parkinson's disease, Alzheimer's disease and depression. The last decade has seen advances in imaging the structure and function of the LC, and this paper systematically reviews the methodology and outcomes of sixty-nine structural and functional MRI studies of the LC in humans. Structural MRI studies consistently showed lower LC signal intensity and volume in clinical groups compared to healthy controls. Within functional studies, the LC was activated by a variety of tasks/stimuli and had functional connectivity to a range of brain regions. However, reported functional LC location coordinates were widely distributed compared to previously published neuroanatomical locations. Methodological and demographic factors potentially contributing to these differences are discussed, together with recommendations to optimize the reliability and validity of future LC imaging studies.
Collapse
|
18
|
Lukaszewicz AC, Dereu D, Gayat E, Payen D. The relevance of pupillometry for evaluation of analgesia before noxious procedures in the intensive care unit. Anesth Analg 2015; 120:1297-300. [PMID: 25993266 DOI: 10.1213/ane.0000000000000609] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many patients in the intensive care unit are unable to communicate verbally. Accurately predicting whether such patients will exhibit painful behaviors during noxious procedures and assessing the adequacy of analgesia during those procedures is a challenge. In addition to observational pain assessment tools such as the Behavioral Pain Scale, physiologic indicators such as the pupillary response have been proposed. The pupil is innervated by both divisions of the autonomic nervous system and is affected by pain and analgesic medications. We evaluated the pupillary response to a light stimulus before noxious procedures as a method to predict pain during the procedure. METHODS We correlated different aspects of the pupillary light reflex with established strategies for pain assessment to evaluate the adequacy of analgesia before surgical dressing changes performed in the intensive care unit in patients with cellulitis associated with mediastinitis or not. RESULTS We found that a percentage of variation in pupil size >19% predicted the presence of pain as assessed by a Behavioral Pain Scale score of >3 with a sensitivity of 100% (95% confidence interval, 100%-100%) and a specificity of 77% (95% confidence interval, 54%-100%). CONCLUSIONS In patients unable to communicate verbally, pupillometry may potentially guide caregivers to adjust analgesia before noxious procedures.
Collapse
Affiliation(s)
- Anne-Claire Lukaszewicz
- From the Department of Anesthesiology and Critical Care, Lariboisière Hospital, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
| | | | | | | |
Collapse
|
19
|
|
20
|
Pupillary Reflex Dilation to Predict Movement: A Step Forward Toward Real-time Individualized Intravenous Anesthetics. Anesthesiology 2015; 122:961-3. [PMID: 25730337 DOI: 10.1097/aln.0000000000000625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
21
|
Fentanyl, an agonist at the mu opioid receptor, depresses pupillary unrest. Auton Neurosci 2015; 189:68-74. [PMID: 25737234 DOI: 10.1016/j.autneu.2015.01.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 12/02/2014] [Accepted: 01/06/2015] [Indexed: 11/21/2022]
Abstract
Pupillary unrest is a chaotic fluctuation in pupil size that is observed in darkness with the onset of drowsiness, and in ambient light. The mechanism of pupillary unrest in darkness as well as in ambient light is unknown but studies suggest that it is caused by fluctuating activity in the Edinger-Westphal (E.W.) nucleus. Neurons in the periaqueductal gray with oscillating firing patterns that are inhibitory to the E.W. nucleus have been described in the cat. We theorized that such oscillating neurons produce pupillary unrest in light and would be depressed by agents, such as opioids, known to depress inhibitory pathways in the midbrain. An infrared pupillometer was used to measure the effect of light on pupillary unrest in eight volunteer subjects, and on 20 patients scheduled for knee arthroscopy who received fentanyl as premedication. Pupillary unrest was quantified through spectral analysis of fast Fourier transforms. Sixteen-second measurements of pupil size at 33 Hz were filtered to eliminate blink artifacts and baseline drift. Pupillary unrest was augmented by excitation of the E.W. nucleus by light and was depressed by 40 ± 20% after the administration of the moderate dose of 1 mcg/kg of fentanyl. Recovery from the drug effect was observed. Based upon the data from this study we propose that pupillary unrest in light originates within oscillating inhibitory neurons that intermittently depress the E. W. nucleus.
Collapse
|
22
|
Abstract
The autonomic nervous system influences numerous ocular functions. It does this by way of parasympathetic innervation from postganglionic fibers that originate from neurons in the ciliary and pterygopalatine ganglia, and by way of sympathetic innervation from postganglionic fibers that originate from neurons in the superior cervical ganglion. Ciliary ganglion neurons project to the ciliary body and the sphincter pupillae muscle of the iris to control ocular accommodation and pupil constriction, respectively. Superior cervical ganglion neurons project to the dilator pupillae muscle of the iris to control pupil dilation. Ocular blood flow is controlled both via direct autonomic influences on the vasculature of the optic nerve, choroid, ciliary body, and iris, as well as via indirect influences on retinal blood flow. In mammals, this vasculature is innervated by vasodilatory fibers from the pterygopalatine ganglion, and by vasoconstrictive fibers from the superior cervical ganglion. Intraocular pressure is regulated primarily through the balance of aqueous humor formation and outflow. Autonomic regulation of ciliary body blood vessels and the ciliary epithelium is an important determinant of aqueous humor formation; autonomic regulation of the trabecular meshwork and episcleral blood vessels is an important determinant of aqueous humor outflow. These tissues are all innervated by fibers from the pterygopalatine and superior cervical ganglia. In addition to these classical autonomic pathways, trigeminal sensory fibers exert local, intrinsic influences on many of these regions of the eye, as well as on some neurons within the ciliary and pterygopalatine ganglia.
Collapse
Affiliation(s)
- David H McDougal
- Neurobiology of Metabolic Dysfunction Laboratory, Pennington Biomedical Research Center, USA Department of Ophthalmology, University of Alabama at Birmingham, USA
| | | |
Collapse
|
23
|
Constant I, Sabourdin N. Monitoring depth of anesthesia: from consciousness to nociception. A window on subcortical brain activity. Paediatr Anaesth 2015; 25:73-82. [PMID: 25410376 DOI: 10.1111/pan.12586] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2014] [Indexed: 11/28/2022]
Abstract
Anesthesia results from several inhibitor processes, which interact to lead to loss of consciousness, amnesia, immobility, and analgesia. The anesthetic agents act on the whole brain, the cortical and subcortical areas according to their receptor targets. The conscious processes are rather integrated at the level of the cortical neuronal network, while the nonconscious processes such as the nociception or implicit memory require subcortical processing. A reliable and meaningful monitoring of depth of anesthesia should provide assessment of these different processes. Besides the EEG monitoring which gives mainly information on cortical anesthetic effects, it would be relevant to have also a subcortical feedback allowing an assessment of nociception. Several devices have been proposed in this last decade, to give us an idea of the analgesia/nociception balance. Up to now, most of them are based on the assessment of the autonomic response to noxious stimulation. Among the emerging clinical devices, we can mention those which assess vascular sympathetic response (skin conductance), cardiac and vascular sympathetic response (surgical pleth index), parasympathetic cardiac response (analgesia nociception index), and finally the pupillometry which is based on the assessment of the pupillary reflex dilatation induced by nociceptive stimulations. Basically, the skin conductance might be the most adapted to assess the stress in the awake or sedated neonate, while the performances of this method appear disappointing under anesthesia. The surgical pleth index is still poorly investigated in children. The analgesia nociception index showed promising results in adults, which have to be confirmed, especially in children and in infants, and lastly pupillometry, which can be considered as reliable and reactive in children as in adults, but which is still sometimes complicated in its use.
Collapse
Affiliation(s)
- Isabelle Constant
- Department of Anesthesiology and Intensive Care, Hopital Armand Trousseau, Paris, France
| | | |
Collapse
|
24
|
Chapman CR, Bradshaw DH, Donaldson GW, Jacobson RC, Nakamura Y. Central noradrenergic mechanisms and the acute stress response during painful stimulation. J Psychopharmacol 2014; 28:1135-42. [PMID: 25122041 DOI: 10.1177/0269881114543718] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Events that threaten tissue integrity including noxious stimulation activate central noradrenergic circuits, particularly locus coeruleus and its projections. Recent advances in theory hold that an adaptive, defensive shift in brain activity takes place in response to threat. In principle, this shift may accentuate the autonomic and central biomarkers of the perception of painful events and the experience of pain itself. We have examined the effects of an alpha-2 agonist on pupil dilation responses, skin conductance responses, near field somatosensory evoked potentials and pain reports in normal volunteers undergoing repeated trials of painful fingertip stimulation delivered at low, medium and high intensities. In a double-blinded study, 114 healthy male and female volunteers underwent repeated noxious stimulation under baseline, placebo and active drug conditions where the active drug was the alpha-2 agonist tizanidine 4 mg. In contrast to baseline and placebo conditions, tizanidine 4 mg significantly reduced the magnitudes of the mean pupil dilation response, the mean skin conductance response, the mean near field somatosensory evoked potential peak-to-peak amplitude and the mean pain intensity rating. Stimulus intensity significantly altered all three biomarkers and the pain report in a graded fashion. There were no sex differences. These findings support the hypotheses that painful events activate central noradrenergic circuits, and that these circuits play a role in the autonomic and central arousal associated with pain.
Collapse
Affiliation(s)
- C Richard Chapman
- Department of Anesthesiology, Pain Research Center, University of Utah, Salt Lake City, UT, USA
| | - David H Bradshaw
- Department of Anesthesiology, Pain Research Center, University of Utah, Salt Lake City, UT, USA
| | - Gary W Donaldson
- Department of Anesthesiology, Pain Research Center, University of Utah, Salt Lake City, UT, USA
| | - Robert C Jacobson
- Department of Anesthesiology, Pain Research Center, University of Utah, Salt Lake City, UT, USA
| | - Yoshio Nakamura
- Department of Anesthesiology, Pain Research Center, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
25
|
Abstract
Abstract
Background:
The pupillary light reflex is a critical component of the neurologic examination, yet whether it is present, depressed, or absent is unknown in patients with significant opioid toxicity. Although opioids produce miosis by activating the pupillary sphincter muscle, these agents may induce significant hypercarbia and hypoxia, causing pupillary constriction to be overcome via sympathetic activation. The presence of either “pinpoint pupils” or sympathetically mediated pupillary dilation might prevent light reflex assessment. This study was designed to determine whether the light reflex remains quantifiable during opioid-induced hypercarbia and hypoxia.
Methods:
Ten volunteers were administered remifentanil with a gradually increasing infusion rate and intermittent boluses, until the increasing respiratory depression produced an oxyhemoglobin saturation of 85% or less with associated hypercarbia. Subjects’ heart rate, blood pressure, respiration, and transcutaneous carbon dioxide level were continuously recorded. Arterial blood gases and pupillary measures were taken before opioid administration, at maximal desaturation, and 15 min after recovery.
Results:
The opioid-induced oxygen desaturation (≤85%) was associated with significant hypercarbia and evidence of sympathetic activation. During maximal hypoxia and hypercarbia, the pupil displayed parasympathetic dominance (2.5 ± 0.2 mm diameter) with a robust quantifiable light reflex. The reflex amplitude was linearly related to pupil diameter.
Conclusions:
Opioid administration with significant accompanying hypercarbia and hypoxia results in pupil diameters of 2 to 3 mm and a reduced but quantifiable pupillary light reflex. The authors conclude that the pupillary examination and evaluation of the light reflex remain useful for neurologic assessment during opioid toxicity.
Collapse
|
26
|
Abstract
We present a case of dexmedetomidine toxicity in a 3-year-old child. The case report describes the features and outlines the treatment strategy adopted. The child presented with bradypnoea, bradycardia, hypotension, deep hypnosis and miosis. He was successfully managed with oxygen, saline boluses and adrenaline infusion. He became haemodynamically stable with adrenaline infusion. He started responding to painful stimuli in 3 h and became oriented in 7 h. Dexmedetomidine, a selective α2 adrenoceptor agonist, is claimed to have a wide safety margin. This case report highlights the fact that dexmedetomidine administered in a toxic dose may be life-threatening may present with miosis and adrenaline infusion may be a useful supportive treatment.
Collapse
Affiliation(s)
- Soumya S Nath
- Department of Anaesthesiology, Sahara Hospital, Viraj Khand, Lucknow, Uttar Pradesh, India
| | | | | |
Collapse
|
27
|
Paulus J, Roquilly A, Beloeil H, Théraud J, Asehnoune K, Lejus C. Pupillary reflex measurement predicts insufficient analgesia before endotracheal suctioning in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R161. [PMID: 23883683 PMCID: PMC4056098 DOI: 10.1186/cc12840] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 07/17/2013] [Indexed: 11/17/2022]
Abstract
Introduction This study aimed to evaluate the pupillary dilatation reflex (PDR) during a tetanic stimulation to predict insufficient analgesia before nociceptive stimulation in the intensive care unit (ICU). Methods In this prospective non-interventional study in a surgical ICU of a university hospital, PDR was assessed during tetanic stimulation (of 10, 20 or 40 mA) immediately before 40 endotracheal suctionings in 34 deeply sedated patients. An insufficient analgesia during endotracheal suction was defined by an increase of ≥1 point on the Behavioral Pain Scale (BPS). Results A total of 27 (68%) patients had insufficient analgesia. PDR with 10 mA, 20 mA and 40 mA stimulation was higher in patients with insufficient analgesia (P <0.01). The threshold values of the pupil diameter variation during a 10, 20 and 40 mA tetanic stimulation to predict insufficient analgesia during an endotracheal suctioning were 1, 5 and 13% respectively. The areas (95% confidence interval) under the receiver operating curve were 0.70 (0.54 to 0.85), 0.78 (0.61 to 0.91) and 0.85 (0.721 to 0.954) with 10, 20 and 40 mA tetanic stimulations respectively. A sensitivity analysis using the Richmond Agitation Sedation Scale (RASS) confirmed the results. The 40 mA stimulation was poorly tolerated. Conclusions In deeply sedated mechanically ventilated patients, a pupil diameter variation ≥5% during a 20 mA tetanic stimulation was highly predictable of insufficient analgesia during endotracheal suction. A 40 mA tetanic stimulation is painful and should not be used.
Collapse
|
28
|
Rouche O, Wolak-Thierry A, Destoop Q, Milloncourt L, Floch T, Raclot P, Jolly D, Cousson J. Evaluation of the depth of sedation in an intensive care unit based on the photo motor reflex variations measured by video pupillometry. Ann Intensive Care 2013; 3:5. [PMID: 23433043 PMCID: PMC3605207 DOI: 10.1186/2110-5820-3-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 01/04/2013] [Indexed: 11/17/2022] Open
Abstract
Background Evaluating depth of sedation in the intensive care unit (ICU) is crucial for the management of mechanically ventilated patients but can be challenging in some situations. Because the depth of hypnosis is correlated with the decrease in photomotor reflex (PMR), we suggest using pupillometric video as an automated, noninvasive, simple, and reproducible technique to evaluate the depth of sedation in ICU patients. We compare the effectiveness of this procedure to the bispectral index (BIS). Methods Thirty-one patients requiring sedation and ventilation were included in this monocentric, observational study. The posology of hypnotics and morphinics were based on the Richmond Agitation and Sedation Scale (RASS). PMR was measured by the Neurolight® (IDMED) system and BIS value by BIS Vista® (Anandic Medical Systems). RASS, PMR, and BIS were measured three times daily in all patients. Data acquired by pupillometric video included variation in pupillary diameter (ΔPD), latency time (LT), and maximal speed of pupillary constriction (Vmax). These parameters were analyzed after having classified BIS values in three groups (<40 heavy sedation; 40 ≤ BIS ≤ 60 acceptable sedation; >60 light sedation). Exclusion criteria were neurological or ophthalmologic pathologies that could interfere with PMR. Results There was a significant difference in Vmax and ΔPD between the BIS < 40 group and 40 ≤ BIS ≤ 60 groups (p < 0.0001 for each) and between the BIS < 40 and BIS > 60 groups (p < 0.0001 for each). There were no significant differences in Vmax and ΔPD between the 40 ≤ BIS ≤ 60 and BIS > 60 groups. There was no correlation between any of the BIS groups and LT. Conclusions Vmax and ΔPD seem to be relevant criteria compared with the BIS and the RASS. Pupillometric video monitoring of depth of sedation could be beneficial in ICU patients, especially for those under myorelaxant drugs, where no clinical evaluation of sedation is possible.
Collapse
Affiliation(s)
- Ouri Rouche
- Service de Réanimation Polyvalente Hôpital Robert Debré, Reims Cedex, CHU 51092, France.
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Martínez-Ricarte F, Castro A, Poca M, Sahuquillo J, Expósito L, Arribas M, Aparicio J. Infrared pupillometry. Basic principles and their application in the non-invasive monitoring of neurocritical patients. NEUROLOGÍA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.nrleng.2010.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
|
30
|
Szabadi E. Modulation of physiological reflexes by pain: role of the locus coeruleus. Front Integr Neurosci 2012; 6:94. [PMID: 23087627 PMCID: PMC3474280 DOI: 10.3389/fnint.2012.00094] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 09/27/2012] [Indexed: 11/13/2022] Open
Abstract
The locus coeruleus (LC) is activated by noxious stimuli, and this activation leads to inhibition of perceived pain. As two physiological reflexes, the acoustic startle reflex and the pupillary light reflex, are sensitive to noxious stimuli, this review considers evidence that this sensitivity, at least to some extent, is mediated by the LC. The acoustic startle reflex, contraction of a large body of skeletal muscles in response to a sudden loud acoustic stimulus, can be enhanced by both directly ("sensitization") and indirectly ("fear conditioning") applied noxious stimuli. Fear-conditioning involves the association of a noxious (unconditioned) stimulus with a neutral (conditioned) stimulus (e.g., light), leading to the ability of the conditioned stimulus to evoke the "pain response". The enhancement of the startle response by conditioned fear ("fear-potentiated startle") involves the activation of the amygdala. The LC may also be involved in both sensitization and fear potentiation: pain signals activate the LC both directly and indirectly via the amygdala, which results in enhanced motoneurone activity, leading to an enhanced muscular response. Pupil diameter is under dual sympathetic/parasympathetic control, the sympathetic (noradrenergic) output dilating, and the parasympathetic (cholinergic) output constricting the pupil. The light reflex (constriction of the pupil in response to a light stimulus) operates via the parasympathetic output. The LC exerts a dual influence on pupillary control: it contributes to the sympathetic outflow and attenuates the parasympathetic output by inhibiting the Edinger-Westphal nucleus, the preganglionic cholinergic nucleus in the light reflex pathway. Noxious stimulation results in pupil dilation ("reflex dilation"), without any change in the light reflex response, consistent with sympathetic activation via the LC. Conditioned fear, on the other hand, results in the attenuation of the light reflex response ("fear-inhibited light reflex"), consistent with the inhibition of the parasympathetic light reflex via the LC. It is suggested that directly applied pain and fear-conditioning may affect different populations of autonomic neurones in the LC, directly applied pain activating sympathetic and fear-conditioning parasympathetic premotor neurones.
Collapse
Affiliation(s)
- Elemer Szabadi
- Psychopharmacology Section, Division of Psychiatry, University of NottinghamNottingham, UK
| |
Collapse
|
31
|
Payen JF, Isnardon S, Lavolaine J, Bouzat P, Vinclair M, Francony G. [Pupillometry in anesthesia and critical care]. ACTA ACUST UNITED AC 2012; 31:e155-9. [PMID: 22681869 DOI: 10.1016/j.annfar.2012.04.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pupil size reflects the balance between sympathetic and parasympathetic systems. Due to technological advances, accurate and repeated pupil size measurements are possible using infrared, video-recorded pupillometers. Two pupil size reflexes are assessed: the pupillary reflex dilation during noxious stimulation, and the pupil light reflex when the pupil is exposed to the light. The pupillary reflex dilation estimates the level of analgesia in response to a painful procedure or to a calibrated noxious stimulus, i.e., tetanic stimulus, in nonverbal patients. This might be of particular interest in optimizing the management of opioids in anaesthetized patients and in assessing pain levels in the intensive care unit. The pupil light reflex measurement is part of the routine monitoring for severely head-injured patients. The impact of pupillometry in this condition remains to be determined.
Collapse
Affiliation(s)
- J-F Payen
- Pôle d'anesthésie-réanimation, hôpital Albert-Michallon, BP 217, 38043 Grenoble cedex 09, France.
| | | | | | | | | | | |
Collapse
|
32
|
Infrared pupillometry. Basic principles and their application in the non-invasive monitoring of neurocritical patients. Neurologia 2010; 28:41-51. [PMID: 21163229 DOI: 10.1016/j.nrl.2010.07.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 07/08/2010] [Accepted: 07/13/2010] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Pupil assessment is a fundamental part of the neurological examination. Size and reactivity to light of each pupil should be recorded periodically since changes in these parameters may represent the only detectable sign of neurological deterioration in some patients. However, there is great intraobserver and interobserver variability in pupil examination due to the influence of many factors, such as the difference in ambient lighting, the visual acuity and experience of the examiner, the intensity of the luminous stimulus, and the method used to direct this stimulus. In recent years, digital cameras have incorporated infrared devices allowing the development of user-friendly portable devices that permit repeated, non-invasive examinations of pupil size and its reactivity to light with an objective, accessible and inexpensive method. DEVELOPMENT The purpose of this review is to describe the fundamentals of infrared pupillometry and discuss potential applications in the monitoring of neurocritical patients. We also present some recommendations in the routine assessment of pupils in neurocritical patients. CONCLUSIONS The possibility of evaluating the changes in pupil reactivity in an early, objective and almost continuous way provides a new non-invasive monitoring method. This method could improve the predictive factor of neurological deterioration and the bedside monitoring of the neurological state of the patient, avoiding unnecessary examinations and enabling early therapeutic intervention.
Collapse
|
33
|
Eilers H, Larson MD. The effect of ketamine and nitrous oxide on the human pupillary light reflex during general anesthesia. Auton Neurosci 2010; 152:108-14. [DOI: 10.1016/j.autneu.2009.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 10/13/2009] [Accepted: 10/14/2009] [Indexed: 11/27/2022]
|
34
|
Evaluations of physiologic reactivity and reflexive behaviors during noxious procedures in sedated critically ill patients. J Crit Care 2009; 24:472.e9-13. [PMID: 19327307 DOI: 10.1016/j.jcrc.2008.07.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 05/11/2008] [Accepted: 07/06/2008] [Indexed: 11/21/2022]
Abstract
PURPOSE Sedated patients' responses to noxious stimulation are not well characterized. A standardized measure of nociception for use in the intensive care unit (ICU) is elusive. The study aimed to describe cardiovascular and pupil reactivity and behavioral responses between noxious and nonnoxious procedures in sedated ICU patients. MATERIALS AND METHODS This prospective, descriptive study performed repeated measures using within-subject and crossover techniques. Forty-eight sedated, ventilated cardiac surgery patients from 2 institutions were included. Pupil sizes, heart rate, blood pressure, cortical arousal changes per the bispectral index, and behaviors were recorded at baseline, during, and after a noxious procedure (endotracheal suctioning or turning), and gentle touch. RESULTS The majority of patients was deeply sedated with propofol infusion and were unresponsive or responsive only to physical stimulation. Significant changes in heart rate, pupil size, and bispectral index occurred with the noxious procedure but not with the nonnoxious procedure (P < .01). Reflexive behaviors were not evident during both procedures. CONCLUSIONS Certain physiologic reactions and pupil size changes may be potentially useful nociceptive indicators in ICU settings. Further research is needed to determine the clinical parameters of physiologic response change and to evaluate the effects of opioids and sedatives on these physiologic responses.
Collapse
|
35
|
Erdurmus M, Aydin B, Usta B, Yagci R, Gozdemir M, Totan Y. Patient comfort and surgeon satisfaction during cataract surgery using topical anesthesia with or without dexmedetomidine sedation. Eur J Ophthalmol 2008; 18:361-7. [PMID: 18465717 DOI: 10.1177/112067210801800308] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the safety and efficacy of perioperative dexmedetomidine (Dex) sedation on patient comfort and surgeon satisfaction during cataract surgery under topical anesthesia. METHODS Forty-four patients having routine clear corneal phacoemulsification surgery under topical anesthesia were included in the study. Patients were randomly divided into two groups: Dex group (n=22) and control group (n=22). Patients in the Dex group were to receive intravenous Dex using an infusion pump and those in the control group were to receive 0.9% saline infusion. Primary outcome measures were patient comfort, surgeon satisfaction, and patient pain perception. RESULTS There was no significant difference between the groups in terms of baseline characteristics including age, sex, eye side, pupil diameter, and vital signs (p>0.05 for all). Patient comfort and surgeon satisfaction in Dex group was better than in control group (p=0.042 and p=0.003, respectively). The mean pain perception score was lesser in the Dex group (1.23+-.72) than control group (3.64+/-1.43), (p<0.001). The mean surgical time and intraoperative complications were similar in both groups (p>0.05). There was no significant effect of the Dex sedation on vital signs perioperatively (p>0.05 for all). CONCLUSIONS Dex sedation improved patient and surgeon satisfaction and decreased patients' pain perception while undergoing cataract surgery under topical anesthesia. It appears to be a safe and suitable choice of sedation for cataract surgery.
Collapse
Affiliation(s)
- M Erdurmus
- Department of Ophthalmology, Fatih University Medical School, Ankara - Turkey.
| | | | | | | | | | | |
Collapse
|
36
|
Larson MD. Mechanism of opioid-induced pupillary effects. Clin Neurophysiol 2008; 119:1358-64. [DOI: 10.1016/j.clinph.2008.01.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Revised: 12/04/2007] [Accepted: 01/22/2008] [Indexed: 10/22/2022]
|
37
|
Oka S, Chapman CR, Kim B, Nakajima I, Shimizu O, Oi Y. Pupil dilation response to noxious stimulation: Effect of varying nitrous oxide concentration. Clin Neurophysiol 2007; 118:2016-24. [PMID: 17646133 DOI: 10.1016/j.clinph.2007.04.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2006] [Revised: 03/29/2007] [Accepted: 04/28/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This report examines the pain-related pupil dilation response (PDR), tracking it across mixture concentrations of nitrous oxide (N(2)O) in oxygen (O(2)) and relating its variation to change in long latency somatosensory evoked potentials (SEPs) and visual analogue scale (VAS) pain report. METHODS We varied mixture concentrations of N(2)O in O(2) (0%, 10%, 30%, and 50%), measuring PDR, SEP and VAS responses to painful electrical fingertip stimulation at high and low intensities in 15 volunteers. RESULTS Mixed effect model statistical analyses revealed that: (1) PDR increased significantly with stimulus intensity and constricted significantly with mixture concentration; (2) SEP and VAS decreased significantly with increasing mixture concentration; (3) PDR correlated with SEP amplitude and VAS across mixture concentrations; (4) subjects differed significantly in: (a) baseline PDR and SEP amplitudes, (b) rate of change of these measures across mixture concentrations; and (5) VAS increased significantly with stimulus intensity and decreased significantly with mixture concentration without significant individual differences. CONCLUSIONS The findings support the hypothesis that the pain-related PDR is a complex brain-mediated response rather than a simple sympathetic reflex. SIGNIFICANCE PDR may provide a useful indicator for studying the central processing of noxious stimuli and the effects of analgesic interventions.
Collapse
Affiliation(s)
- Shunichi Oka
- Department of Dental Anesthesiology, Nihon University School of Dentistry, 1-8-13, Kanda Surugadai Tokyo 101-8310, Japan.
| | | | | | | | | | | |
Collapse
|
38
|
Abstract
The aim of this study was to identify receptors that mediate reflex mydriasis in pentobarbital-anesthetized rabbits, in which the cervical sympathetic nerve was sectioned unilaterally. Voltage-response curves of pupillary dilation were generated bilaterally by stimulation of the sciatic nerve. Evoked mydriatic responses were mediated mainly by efferent parasympathetic innervation, and, to a lesser extent, by sympathetic innervation. The alpha-adrenergic antagonist, phenoxybenzamine (0.3 mg/kg, intravenously (i.v.)), antagonized mydriasis of the neurally intact eye, but not that on the sympathectomized side. The alpha2-adrenergic antagonist, RS 79948 (0.3 mg/kg, i.v.), potentiated mydriasis of the normal eye, but was without either a potentiating or inhibitory effect on the mydriasis of the sympathectomized eye. In addition, the dopamine-receptor antagonist, haloperidol (1 mg/kg, i.v.), inhibited evoked mydriasis of the sympathectomized eye. These results suggest that, unlike some other species (cats and rats), alpha2-adrenoceptors do not mediate reflex mydriasis elicited by sciatic-nerve stimulation in the rabbit, and support the previous finding in humans that dopamine receptors may mediate this response.
Collapse
Affiliation(s)
- Yongxin Yu
- Department of Cell Biology, University of Oklahoma College of Medicine, Oklahoma City, OK 73190, USA.
| | | |
Collapse
|
39
|
Hou RH, Freeman C, Langley RW, Szabadi E, Bradshaw CM. Does modafinil activate the locus coeruleus in man? Comparison of modafinil and clonidine on arousal and autonomic functions in human volunteers. Psychopharmacology (Berl) 2005; 181:537-49. [PMID: 15983798 DOI: 10.1007/s00213-005-0013-8] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2004] [Accepted: 03/31/2005] [Indexed: 11/29/2022]
Abstract
RATIONALE Modafinil is a wakefulness-promoting drug which is likely to activate some wakefulness-promoting and/or inhibit sleep-promoting neurones in the brain. The locus coeruleus (LC) is a wakefulness-promoting noradrenergic nucleus whose activity can be "switched off" by the alpha2-adrenoceptor agonist clonidine, leading to sedative and sympatholytic effects. OBJECTIVE The aim of the study is to compare the effects of single doses of modafinil and clonidine on arousal and autonomic functions in human volunteers. METHODS Sixteen healthy male volunteers participated in four experimental sessions (modafinil 200 mg; clonidine 0.2 mg; modafinil 200 mg + clonidine 0.2 mg; placebo) at weekly intervals, according to a balanced double-blind protocol. Arousal [pupillary "fatigue waves" (PFW), critical flicker fusion frequency, self-ratings of alertness] and autonomic functions (pupil diameter, pupillary light and darkness reflex responses, blood pressure, heart rate, salivation) were recorded. Data were analyzed with ANOVA, with multiple comparisons. RESULTS Clonidine reduced subjective alertness, pupil diameter, the initial velocity and amplitude of the darkness reflex response, systolic and diastolic blood pressure and salivation, prolonged the recovery time of the light reflex response and increased PFW. Modafinil reduced PFW, increased pupil diameter and the initial velocity of the darkness reflex response and tended to reduce the effect of clonidine on pupil diameter and PFW. Modafinil had no effect on non-pupillary autonomic functions. CONCLUSIONS Clonidine exerted sympatholytic and sedative effects, whereas modafinil had sympathomimetic and some alerting effects. Modafinil may activate noradrenergic neurones in the LC involved in arousal and pupillary control, without affecting extracoerulear noradrenergic neurones involved in cardiovascular and salivary regulation.
Collapse
Affiliation(s)
- R H Hou
- Psychopharmacology Section, Division of Psychiatry, University of Nottingham, Room B109, Medical School, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | | | | | | | | |
Collapse
|
40
|
Larson MD, Berry PD, May J, Bjorksten A, Sessler DI. Latency of pupillary reflex dilation during general anesthesia. J Appl Physiol (1985) 2004; 97:725-30. [PMID: 15247200 DOI: 10.1152/japplphysiol.00098.2004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Areas of insensibility produced by neuraxial anesthesia or peripheral nerve blocks can be detected during general anesthesia by failure of noxious stimulation to trigger pupillary reflex dilation. We examined the latency of pupillary reflex dilation and the effect of fentanyl on the latency of reflex dilation during anesthesia in nine volunteers. We hypothesized that the reflex was generated by slowly conducting C nociceptive fibers and would be significantly delayed if a distal dermatome (L4) was stimulated compared with a proximal dermatome (C5). We also hypothesized that fentanyl would prolong the latency and alter the shape of the reflex. After induction of general anesthesia, pupillary reflex dilation was measured with an infrared pupillometer every 5 min after stimulations of the L4 and C5 dermatomes. Fentanyl (3 μg/kg) was then given intravenously. Pupillary reflex dilation latencies were calculated by examining each individual measurement. After 3 h, naloxone (400 μg) was given intravenously; anesthesia was then discontinued. Pupillary reflex dilation had a long latency and consisted of distinct early and late phases. No differences were found between latencies of reflex dilation after simulation of L4 and C5 dermatomes either before or after fentanyl administration. Fentanyl at high concentrations essentially eliminated pupillary reflex dilation; but over the 180-min observation period, first early and then late dilation returned. Fentanyl produced a small increase in the latency of the initial early dilation. We conclude that pupillary reflex dilation during anesthesia is not initiated by slowly conducting C fibers and that fentanyl depresses the reflex in a stereotypical manner.
Collapse
Affiliation(s)
- Merlin D Larson
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA 94143-0648, USA.
| | | | | | | | | |
Collapse
|
41
|
Abstract
UNLABELLED The effect of dopamine D2 receptor antagonists, such as chlorpromazine and haloperidol, on pupil size in awake subjects suggests that these drugs might also alter pupillary reflex dilation and pupil size during general anesthesia. Forty-seven patients undergoing lower abdominal surgery under combined epidural/general anesthesia were randomized to receive one of the 5 following open labeled drugs: 10 mL saline, 0.13 mg/kg ondansetron, 0.25 mg/kg metoclopramide, 0.5 mg/kg metoclopramide, or 0.02 mg/kg droperidol. Three measurements of reflex dilation were taken at 5-min intervals and after the last measurement (time 0) the drug was administered. Measurements were then taken 5, 10, 20, and 40 min after I.V. drug administration. Reflex dilation was induced by intermittent noxious stimulation of the C5 dermatome with a tetanic electric current (60-70 mamp, 100 Hz, 3-s duration) after a stable level of epidural analgesia had been established with 3/8% bupivacaine and maintained with a continuous infusion. Metoclopramide produced a small decrease in pupil diameter and transiently depressed reflex dilation, whereas droperidol decreased pupil size at 10 min and depressed reflex dilation throughout the 40-min study period. Maximal change in reflex dilation was -6.6 +/- 3.3 mm-sec after droperidol. Ondansetron had no effect on pupil diameter or reflex dilation. When pupillary diameter measurements are used to gauge opioid levels during experimental conditions or during surgical anesthesia, antiemetic medication acting on the dopamine D2 receptor should be avoided. IMPLICATIONS Miosis is often considered an effect of opioid administration during general anesthesia, but other drugs, such as antiemetics, might produce a similar effect on the pupil. This study demonstrates that 2 antiemetics, droperidol and metoclopramide, constrict the pupil and block the pupillary dilation brought about by nociceptive stimuli.
Collapse
Affiliation(s)
- Merlin D Larson
- From the Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| |
Collapse
|