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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.
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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.
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Maxin AJ, Gulek BG, Lee C, Lim D, Mariakakis A, Levitt MR, McGrath LB. Response to Zanier and Citerio, Evaluating a Pupillometry App Considering Sedation's Impact: A Step Unexplored (DOI: 10.1089/neu.2023.0431). J Neurotrauma 2024; 41:296-297. [PMID: 37742117 DOI: 10.1089/neu.2023.0468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2023] Open
Affiliation(s)
- Anthony J Maxin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Bernice G Gulek
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Chungeun Lee
- Washington State University, Elson S. Floyd College of Medicine, Spokane, Washington, USA
| | - Do Lim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - Alex Mariakakis
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
- Department of Radiology, University of Washington, Seattle, Washington, USA
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Lynn B McGrath
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
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Monai E, Favaretto C, Salvalaggio A, Pini L, Munari M, Corbetta M. Pupillary dynamics predict long-term outcome in a cohort of acute traumatic brain injury coma patients. Ann Clin Transl Neurol 2023; 10:1854-1862. [PMID: 37641463 PMCID: PMC10578890 DOI: 10.1002/acn3.51879] [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: 02/26/2023] [Revised: 07/08/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE Examining the size and reactivity of the pupils of traumatic brain injury coma patients is fundamental in the Neuro-intensive care unit (ICU). Pupil parameters on admission predict long-term clinical outcomes. However, little is known about the dynamics of pupillary parameters and their potential value for outcome prediction. METHODS This study applied a time-course analysis of pupillary signals (size and photo-reactivity) in acute traumatic brain injury coma patients (n = 20) to predict outcome at 6 months. RESULTS The time course of pupillary signals was informative in discriminating favorable (F) versus unfavorable (U) outcomes, with the highest correlation within the 1st week notwithstanding pharmacological sedation. Patients with favorable outcome at 6 months showed more consistent in time isochoric and photo-reactive pupils. In contrast, patients with an unfavorable outcome showed more variable measures that tended to stabilize toward pathological values. INTERPRETATION Time-dependent tracking of pupils' size and reactivity is a promising application for ICU monitoring and long-term prognosis. These findings support the usefulness of automatic tools for the dynamic, quantitative, and objective measurements of pupils.
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Affiliation(s)
- Elena Monai
- Clinica NeurologicaUniversity Hospital of PadovaPadovaItaly
- Department of NeuroscienceUniversity of PadovaPadovaItaly
| | | | - Anna Salvalaggio
- Clinica NeurologicaUniversity Hospital of PadovaPadovaItaly
- Department of NeuroscienceUniversity of PadovaPadovaItaly
| | - Lorenzo Pini
- Padova Neuroscience Center (PNC)University of PadovaPadovaItaly
| | - Marina Munari
- Neuro‐Intensive Care UnitUniversity Hospital of PadovaPadovaItaly
| | - Maurizio Corbetta
- Clinica NeurologicaUniversity Hospital of PadovaPadovaItaly
- Department of NeuroscienceUniversity of PadovaPadovaItaly
- Padova Neuroscience Center (PNC)University of PadovaPadovaItaly
- Venetian Institute of Molecular Medicine (VIMM)PadovaItaly
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Bauerschmidt A, Al-Bermani T, Ali S, Bass B, Dorilio J, Rosenberg J, Al-Mufti F. Modern Sedation and Analgesia Strategies in Neurocritical Care. Curr Neurol Neurosci Rep 2023; 23:149-158. [PMID: 36881257 DOI: 10.1007/s11910-023-01261-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE OF REVIEW Patients with acute neurologic injury require a specialized approach to critical care, particularly with regard to sedation and analgesia. This article reviews the most recent advances in methodology, pharmacology, and best practices of sedation and analgesia for the neurocritical care population. RECENT FINDINGS In addition to established agents such as propofol and midazolam, dexmedetomidine and ketamine are two sedative agents that play an increasingly central role, as they have a favorable side effect profile on cerebral hemodynamics and rapid offset can facilitate repeated neurologic exams. Recent evidence suggests that dexmedetomidine is also an effective component when managing delirium. Combined analgo-sedation with low doses of short-acting opiates is a preferred sedation strategy to facilitate neurologic exams as well as patient-ventilator synchrony. Optimal care for patients in the neurocritical care population requires an adaptation of general ICU strategies that incorporates understanding of neurophysiology and the need for close neuromonitoring. Recent data continues to improve care tailored to this population.
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Affiliation(s)
- Andrew Bauerschmidt
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
- Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
| | - Tarik Al-Bermani
- Department of Pulmonary, Critical Care, and Sleep Medicine-Westchester Medical Center, Valhalla, NY, USA
| | - Syed Ali
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Brittany Bass
- Department of Pulmonary, Critical Care, and Sleep Medicine-Westchester Medical Center, Valhalla, NY, USA
| | - Jessica Dorilio
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jon Rosenberg
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
- Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurology-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
- Department of Neurosurgery-Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Renaud-Roy E, Morisson L, Brulotte V, Idrissi M, Godin N, Fortier LP, Verdonck O, Choinière M, Richebé P. Effect of combined intraoperative use of the Nociception Level (NOL) and bispectral (BIS) indexes on desflurane administration. Anaesth Crit Care Pain Med 2022; 41:101081. [PMID: 35472586 DOI: 10.1016/j.accpm.2022.101081] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Currently, nociception monitors are not part of standard anaesthesia care. We investigated whether combined intraoperative nociception (NOL index) and anaesthesia (BIS index) monitoring during general anaesthesia would reduce anaesthetics consumption and enhance intraoperative safety and postoperative recovery when compared to standard of care monitoring (SOC). METHODS In this randomised study, we included 60 patients undergoing colonic surgery under desflurane/remifentanil anaesthesia and epidural analgesia. Patients received either standard monitoring or combined BIS + NOL index monitoring. In the monitored group, remifentanil infusion was titrated to achieve a NOL index below 20. Desflurane was adjusted to BIS values (45-55). In the SOC group, remifentanil and desflurane were titrated on vital signs and MAC. The primary outcome was intraoperative desflurane consumption. RESULTS Fifty-five patients were analysed. Desflurane administration was reduced in the monitored group from 0.25 ± 0.05 to 0.20 ± 0.06 mL kg-1 h-1 (p < 0.001). The cumulative time with a BIS under 40 was significantly higher in the SOC group with a median time of 12.6 min (95% CI: 0.6-80.0) versus 2.0 min (95% CI: 0.3-5.83) (p = 0.023). Time for extubation was significantly shorter in the monitored group: 4.4 min (95% CI: 2.4-4.9) versus 6.28 min (95% IC: 5.0-8.2) (p = 0.003). We observed no differences in remifentanil or phenylephrine requirements during anaesthesia or in postoperative outcome measures, such as postoperative pain, opioid consumption, neurocognitive recovery. CONCLUSION Combined intraoperative monitoring of anaesthesia and nociception during colonic surgery resulted in less desflurane consumption and quicker extubation time compared to standard clinical care monitoring.
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Affiliation(s)
- Etienne Renaud-Roy
- Department of Anesthesiology and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada; Department of Anesthesiology and Pain Medicine - Université de Montréal, 2900 Bd Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada
| | - Louis Morisson
- Department of Anesthesiology and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Véronique Brulotte
- Department of Anesthesiology and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada; Centre de Recherche de l'Hôpital Maisonneuve-Rosemont (CR-HMR), CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada; Department of Anesthesiology and Pain Medicine - Université de Montréal, 2900 Bd Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada
| | - Moulay Idrissi
- Department of Anesthesiology and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Nadia Godin
- Department of Anesthesiology and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Louis-Philippe Fortier
- Department of Anesthesiology and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada; Department of Anesthesiology and Pain Medicine - Université de Montréal, 2900 Bd Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada
| | - Olivier Verdonck
- Department of Anesthesiology and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada; Department of Anesthesiology and Pain Medicine - Université de Montréal, 2900 Bd Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada
| | - Manon Choinière
- Department of Anesthesiology and Pain Medicine - Université de Montréal, 2900 Bd Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada; Centre de Recherche du CHUM (CR-CHUM), 900 rue Saint-Denis, Montréal, QC, H2X 0A9, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Hôpital Maisonneuve-Rosemont, CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada; Centre de Recherche de l'Hôpital Maisonneuve-Rosemont (CR-HMR), CIUSSS de l'Est de l'Ile de Montréal, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada; Department of Anesthesiology and Pain Medicine - Université de Montréal, 2900 Bd Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada.
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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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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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8
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Abstract
The intraoperative dosing of opioids is a challenge in routine anesthesia as the potential effects of intraoperative overdosing and underdosing are not completely understood. In recent years an increasing number of monitors were approved, which were developed for the detection of intraoperative nociception and therefore should enable a better control of opioid titration. The nociception monitoring devices use either continuous hemodynamic, galvanic or thermal biosignals reflecting the balance between parasympathetic and sympathetic activity, measure the pupil dilatation reflex or the nociceptive flexor reflex as a reflexive response to application of standardized nociceptive stimulation. This review article presents the currently available nociception monitors. Most of these monitoring devices detect nociceptive stimulations with higher sensitivity and specificity than changes in heart rate, blood pressure or sedation depth monitoring devices. There are only few studies on the effect of opioid titration guided by nociception monitoring and the possible postoperative benefits of these devices. All nociception monitoring techniques are subject to specific limitations either due to perioperative confounders (e.g. hypovolemia) or special accompanying medical conditions (e.g. muscle relaxation). There is an ongoing discussion about the clinical relevance of nociceptive stimulation in general anesthesia and the effect on patient outcome. Initial results for individual monitor systems show a reduction in opioid consumption and in postoperative pain level. Nevertheless, current evidence does not enable the routine use of nociception monitoring devices to be recommended as a clear beneficial effect on long-term outcome has not yet been proven.
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9
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Petpiroon P, Suwan Y, Teekhasaenee C, Supakontanasan W. Pseudophakic Angle Closure Due to Vitreous Block Following Ureteroscopic Lithotripsy. Int Med Case Rep J 2021; 14:21-24. [PMID: 33536795 PMCID: PMC7850374 DOI: 10.2147/imcrj.s285701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/23/2020] [Indexed: 11/23/2022] Open
Abstract
Background Here, we describe a patient who exhibited pseudophakic angle closure due to vitreous block following ureteroscopic lithotripsy under general anesthesia. Case Presentation A 57-year-old Thai man presented with sudden eye pain and blurring of vision in the left eye following ureteroscopic lithotripsy under general anesthesia. The patient had a history of coconut hit into his left eye which resulted in traumatic anterior lens subluxation, for which he had undergone phacoemulsification and scleral-fixated intraocular lens implantation in the left eye. Prior scleral fixation procedure, anterior vitrectomy was not performed. Clinical examination showed mushroom-shaped vitreous in the anterior chamber with absolute pupillary block, which had resulted in acute angle closure. Thus, topical and oral antiglaucoma medications were administered to achieve normal intraocular pressure in the left eye, followed by laser peripheral iridotomy in that eye. The anterior chamber depth was successfully increased. Limited anterior vitrectomy by a pars plana approach was performed to prevent recurrent angle closure. The patient’s vision improved and his intraocular pressure remained controlled without any antiglaucoma medication. Conclusion Vitreous block can occur in patients with pseudophakia, especially in the presence of a ruptured posterior capsule. Cautious intraoperative anterior vitrectomy and surgical iridectomy are warranted. General anesthesia may contribute to the onset of vitreous block in susceptible patients.
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Affiliation(s)
- Purit Petpiroon
- Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Yanin Suwan
- Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chaiwat Teekhasaenee
- Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wasu Supakontanasan
- Department of Ophthalmology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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10
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Affiliation(s)
- Patrick Schober
- From the Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, Texas
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