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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, Chae J, Winston G, Weisbeek P, McGrath LB, Levitt MR. A smartphone pupillometry tool for detection of acute large vessel occlusion. J Stroke Cerebrovasc Dis 2023; 32:107430. [PMID: 37857150 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107430] [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: 09/07/2023] [Revised: 10/03/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023] Open
Abstract
OBJECTIVES Pupillary light reflex (PLR) parameters can be used as quantitative biomarkers of neurological function. Since digital infrared pupillometry is expensive, we sought to examine alterations in PLR parameters using a smartphone quantitative pupillometry platform in subjects with acute ischemic stroke (AIS). MATERIALS AND METHODS Patients were enrolled if they presented to the emergency department as a stroke code activation and had evidence of a large vessel occlusion (LVO) on computed tomography angiography. Controls were enrolled from hospital staff. A smartphone pupillometer was used in AIS patients with LVO pre-mechanical thrombectomy, immediately post-thrombectomy, and at 24 h post-thrombectomy. Clinical and demographic data were collected, along with the proprietary Neurological Pupil index (NPi) score from the NPi-200 digital infrared pupillometer. PLR parameters were compared using mean differences. The absolute and non-absolute inter-eye difference in each parameter for each subject were also analyzed by measuring 1 - (R:L) to determine alteration in the equilibrium between subject pupils. The NPi was analyzed for mean differences between cohorts. RESULTS Healthy controls (n = 132) and AIS patients (n = 31) were enrolled. Significant differences were observed in PLR parameters for healthy subjects when compared to pre-thrombectomy subjects in both mean and absolute inter-eye differences after post hoc Bonferroni correction. The proprietary NPi score was not significantly different for all groups and comparisons. CONCLUSIONS Significant alterations in the PLR were observed in AIS patients with LVO before thrombectomy, indicating the potential use of smartphone pupillometry for detection of LVO.
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Affiliation(s)
- Anthony J Maxin
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA; School of Medicine, Creighton University, Omaha, NE, USA
| | - Bernice G Gulek
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - John Chae
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Graham Winston
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - Lynn B McGrath
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA; Department of Radiology, University of Washington, Seattle, WA, USA; Department of Mechanical Engineering, University of Washington, Seattle, WA, USA; Stroke & Applied Neuroscience Center, University of Washington, Seattle, WA, USA.
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Jiang J, Sari H, Goldman R, Huff E, Hanna A, Samraj R, Gourabathini H, Bhalala U. Neurological Pupillary Index (NPi) Measurement Using Pupillometry and Outcomes in Critically Ill Children. Cureus 2023; 15:e46480. [PMID: 37927706 PMCID: PMC10624239 DOI: 10.7759/cureus.46480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Aim/objective Neurological Pupil Index (NPi), measured by automated pupillometry (AP), allows the objective assessment of pupillary light reflex (PLR). NPi ranges from 0 (non-reactive) to 5 (normal). In this study, we aimed to compare neurologic and functional outcomes in children admitted for neurologic injury with normal (≥3) versus abnormal (<3) NPi measured during their pediatric intensive care unit (PICU) stay. Materials and methods We conducted a retrospective chart review of children between one month and 18 years admitted to our PICU with a diagnosis of neurologic injury between January 2019 and June 2022. We collected demographic, clinical, pupillometer, and outcome data, including mortality, Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and Functional Status Score (FSS) at admission, at discharge, and at the three to six-month follow-up. We defined abnormal pupil response as any NPi <3 at any point during the PICU stay. Using the student's t-test and chi-square test, we compared the short-term and long-term outcomes of children with abnormal NPi (<3) versus those with normal NPi (≥3). Results There were 49 children who met the inclusion criteria and who had pupillometry data available for analysis. The mean (SD) Glasgow Coma Scale (GCS) in the study cohort was 5.6 (4.3), and 61% had low (<3) NPi during ICU stay. Mortality was significantly higher among patients with an abnormal NPi as compared to those with normal NPi. Children with abnormal NPi exhibited significant worsening of neurologic and functional status (ΔPCPC, ΔPOPC, and ΔFSS) from admission to discharge (mean (SD): 3.55(1.5), 3.45(1.43), 16.75(7.85), p<0.001) as compared to those with normal NPi (mean (SD): 1.45(0.93), 1.73(0.90), 3.55(2.07), p>0.05). The significant difference in neurologic and functional status persisted at the three to six-month follow-up between the two groups - children with abnormal NPi (mean (SD): 2.0(1.41), 2.08(1.38), 6.92(6.83), p<0.01) and children with normal NPi (mean (SD): 0.82(1.01), 0.94(1.03), 1.53(1.70), p>0.05). Conclusion In our retrospective cohort study, children admitted to the PICU for a neuro injury and with abnormal NPi (< 3) have higher mortality, and worse short-term and long-term neurologic and functional outcomes as compared to those with normal NPi (≥ 3) measured during the PICU course. AP provides an objective assessment of PLR and has potential applications for neuro-prognostication. More research needs to be done to elucidate the prognostic value of NPi in pediatrics.
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Affiliation(s)
- Jessie Jiang
- Medicine, Texas A&M College of Medicine, Round Rock, USA
| | - Halil Sari
- Statistics, Texas A&M College of Medicine, Round Rock, USA
| | - Rachelle Goldman
- Pediatric Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, USA
| | - Erionne Huff
- Pediatric Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, USA
| | - Ashley Hanna
- Pediatric Neurosurgery, Driscoll Children's Hospital, Corpus Christi, USA
| | - Ravi Samraj
- Pediatric Critical Care Medicine, Driscoll Children's Hospital, Corpus Christi, USA
| | | | - Utpal Bhalala
- Pediatrics, Texas A&M College of Medicine, College Station, USA
- Anesthesiology and Critical Care, Driscoll Children's Hospital, Corpus Christi, USA
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Sparks S, Pinto J, Hayes G, Spitschan M, Bulte DP. The impact of Alzheimer's disease risk factors on the pupillary light response. Front Neurosci 2023; 17:1248640. [PMID: 37650103 PMCID: PMC10463762 DOI: 10.3389/fnins.2023.1248640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/31/2023] [Indexed: 09/01/2023] Open
Abstract
Alzheimer's disease (AD) is the leading cause of dementia, and its prevalence is increasing and is expected to continue to increase over the next few decades. Because of this, there is an urgent requirement to determine a way to diagnose the disease, and to target interventions to delay and ideally stop the onset of symptoms, specifically those impacting cognition and daily livelihood. The pupillary light response (PLR) is controlled by the sympathetic and parasympathetic branches of the autonomic nervous system, and impairments to the pupillary light response (PLR) have been related to AD. However, most of these studies that assess the PLR occur in patients who have already been diagnosed with AD, rather than those who are at a higher risk for the disease but without a diagnosis. Determining whether the PLR is similarly impaired in subjects before an AD diagnosis is made and before cognitive symptoms of the disease begin, is an important step before using the PLR as a diagnostic tool. Specifically, identifying whether the PLR is impaired in specific at-risk groups, considering both genetic and non-genetic risk factors, is imperative. It is possible that the PLR may be impaired in association with some risk factors but not others, potentially indicating different pathways to neurodegeneration that could be distinguished using PLR. In this work, we review the most common genetic and lifestyle-based risk factors for AD and identify established relationships between these risk factors and the PLR. The evidence here shows that many AD risk factors, including traumatic brain injury, ocular and intracranial hypertension, alcohol consumption, depression, and diabetes, are directly related to changes in the PLR. Other risk factors currently lack sufficient literature to make any conclusions relating directly to the PLR but have shown links to impairments in the parasympathetic nervous system; further research should be conducted in these risk factors and their relation to the PLR.
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Affiliation(s)
- Sierra Sparks
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Joana Pinto
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Genevieve Hayes
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Manuel Spitschan
- TUM Department of Sport and Health Sciences (TUM SG), Chronobiology and Health, Technical University of Munich, Munich, Germany
- TUM Institute for Advanced Study (TUM-IAS), Technical University of Munich, Garching, Germany
- Max Planck Institute for Biological Cybernetics, Translational Sensory and Circadian Neuroscience, Tübingen, Germany
| | - Daniel P. Bulte
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
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Hsu CH, Kuo LT. Application of Pupillometry in Neurocritical Patients. J Pers Med 2023; 13:1100. [PMID: 37511713 PMCID: PMC10381796 DOI: 10.3390/jpm13071100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/25/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
Pupillary light reflex (PLR) assessment is a crucial examination for evaluating brainstem function, particularly in patients with acute brain injury and neurosurgical conditions. The PLR is controlled by neural pathways modulated by both the sympathetic and parasympathetic nervous systems. Altered PLR is a strong predictor of adverse outcomes after traumatic and ischemic brain injuries. However, the assessment of PLR needs to take many factors into account since it can be modulated by various medications, alcohol consumption, and neurodegenerative diseases. The development of devices capable of measuring pupil size and assessing PLR quantitatively has revolutionized the non-invasive neurological examination. Automated pupillometry, which is more accurate and precise, is widely used in diverse clinical situations. This review presents our current understanding of the anatomical and physiological basis of the PLR and the application of automated pupillometry in managing neurocritical patients. We also discuss new technologies that are being developed, such as smartphone-based pupillometry devices, which are particularly beneficial in low-resource settings.
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Affiliation(s)
- Chiu-Hao Hsu
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Biomedical Park Hospital, Hsin-Chu County 302, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei 100, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan
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El Boujdaini A, Peluso L, Khaldi A, Macchini E, Minini A, Gouvea Bogossian E, Creteur J, Taccone FS. Prognostic role of automatic pupillometry in sepsis: a retrospective study. Minerva Anestesiol 2022; 88:371-379. [PMID: 35191640 DOI: 10.23736/s0375-9393.22.16092-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Sepsis-associated brain dysfunction is a frequent disorder in septic patients and has a multifactorial pathophysiology. Cholinergic pathways and brainstem dysfunction may result in pupillary alterations. The aim of this study was to evaluate whether early assessment of the Neurological Pupil Index (NPiTM) derived from an automated pupillometry could predict mortality in critically ill septic patients. METHODS Retrospective cohort study of adult critically ill septic patients admitted to the intensive care unit of an University Hospital; patients with acute or known brain damage were excluded. The severity of the patients was assessed by the daily Sequential Organ Failure Assessment score and the SOFAmax (i.e. highest SOFA score during the first 5 days) was computed. The worst NPi (i.e. lowest value from one eye) was collected daily and then computed over the first 5 days of assessment. Mortality was assessed at hospital discharge. RESULTS A total of 75 patients were included over the study period (median age 67 [53-75] years and median SOFA score at admission 10 [8-12]); 64 (85%) presented septic shock; 48 (64%) died at hospital discharge. The worst NPi during the first 5 days of sepsis was significantly lower in non-survivors compared to survivors (4.4 [3.6-4.6] vs. 4.5 [4.2-4.7]; p=0.042). The worst NPi was also significantly lower in high severity group (i.e. SOFAmax≥12) when compared to others (4.4 [3.2- 4.5] vs 4.5 [4.0-4.7] p=0.01). However, in the multivariate analyses, the NPi value was not independently associated with in-hospital mortality or high SOFAmax. CONCLUSIONS In this study, no independent prognostic role of NPi was observed in septic patients. Further larger prospective studies are needed to better evaluate the role of automated pupillometry in this setting.
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Affiliation(s)
- Adil El Boujdaini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium -
| | - Amina Khaldi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Elisabetta Macchini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Luz Teixeira T, Peluso L, Banco P, Njimi H, Abi-Khalil L, Chanchay Pillajo M, Schuind S, Creteur J, Bouzat P, Taccone FS. Early Pupillometry Assessment in Traumatic Brain Injury Patients: A Retrospective Study. Brain Sci 2021; 11:brainsci11121657. [PMID: 34942959 PMCID: PMC8699519 DOI: 10.3390/brainsci11121657] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/06/2021] [Accepted: 12/13/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate whether the early assessment of neurological pupil index (NPi) values derived from automated pupillometry could predict neurological outcome after traumatic brain injury (TBI). METHODS Retrospective observational study including adult (>18 years) TBI patients admitted from January 2018 to December 2020, with available NPi on admission. Abnormal NPi was considered if <3. Unfavorable neurological outcome (UO) at hospital discharge was considered for a Glasgow Outcome Scale of 1-3. RESULTS 100 patients were included over the study period (median age 48 (34-69) years and median GCS on admission 11 (6-15)); 49 (49%) patients had UO. On admission, 20 (20%) patients had an abnormal NPi (NPi < 3); median worst (i.e., from both eyes) NPi was 4.2 (3.2-4.5). Median worst and mean NPi on admission were significantly lower in the UO group than others (3.9 (1.7-4.4) vs. 4.4 (3.7-4.6); p = 0.005-4.0 (2.6-4.5) vs. 4.5 (3.9-4.7); p = 0.002, respectively). The ROC curve for the worst and mean NPi showed a moderate accuracy to predict UO (AUC 0.66 (0.56-0.77); p = 0.005 and 0.68 (0.57-0.78); p = 0.002). However, in a generalized linear model, the prognostic role of NPi on admission was limited. CONCLUSIONS Low NPi on admission has limited prognostic value in TBI.
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Affiliation(s)
- Thomas Luz Teixeira
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Lorenzo Peluso
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Pierluigi Banco
- Department of Anesthesiology and Intensive Care, University of Grenobles, 38400 Grenobles, France; (P.B.); (P.B.)
| | - Hassane Njimi
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Layal Abi-Khalil
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Mélanie Chanchay Pillajo
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Sophie Schuind
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium;
| | - Jacques Creteur
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Pierre Bouzat
- Department of Anesthesiology and Intensive Care, University of Grenobles, 38400 Grenobles, France; (P.B.); (P.B.)
- Grenoble Institute Neurosciences, University of Grenoble Alpes, 38700 Grenoble, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
- Correspondence: ; Tel.: +32-25555587
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Zielinska A, Ciacka P, Szkulmowski M, Komar K. Pupillary Light Reflex Induced by Two-Photon Vision. Invest Ophthalmol Vis Sci 2021; 62:23. [PMID: 34935882 PMCID: PMC8711009 DOI: 10.1167/iovs.62.15.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Two-photon vision relies on the perception of pulsed infrared light due to two-photon absorption in visual pigments. This study aimed to measure human pupil reaction caused by a two-photon 1040-nm stimulus and compare it with pupil responses elicited by 520-nm stimuli of similar color. Methods Pupillary light reflex (PLR) was induced on 14 dark-adapted healthy subjects. Three types of fovea-centered stimuli of 3.5° diameter were tested: spirals formed by fast scanning 1040-nm (infrared [IR] laser) or 520-nm (visible [VIS] laser) laser beams and uniformly filled circle created by 520-nm LED (VIS light-emitting diode [LED]). The power of visible stimuli was determined with a dedicated procedure to obtain the same perceived brightness equivalent as for 800 µW used for two-photon stimulation. Results The minimum pupil diameter for IR laser was 88% ± 10% of baseline, significantly larger than for both VIS stimuli: 74% ± 10% (laser) and 69% ± 9% (LED). Mean constriction velocity and time to maximum constriction had significantly smaller values for IR than for both VIS stimuli. Latency times were similar for IR and VIS lasers and slightly smaller for VIS LED. Conclusions The two-photon stimulus caused a considerably weaker pupil reaction than one-photon stimuli of the same shape, brightness, and similar color. The smaller pupil response may be due to weaker two-photon stimulation of rods relative to cones as previously observed for two-photon vision. Contrary to normal vision, in a two-photon process the stray light is not perceived, which might reduce the number of stimulated photoreceptors and further weaken the PLR.
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Affiliation(s)
- Agnieszka Zielinska
- Institute of Physics, Faculty of Physics, Astronomy and Informatics, Nicolaus Copernicus University in Toruń, Toruń, Poland
| | - Piotr Ciacka
- International Centre for Translational Eye Research, Warsaw, Poland.,Department of Physical Chemistry of Biological Systems, Institute of Physical Chemistry, Polish Academy of Sciences, Kasprzaka 44/52, 01-224 Warsaw, Poland
| | - Maciej Szkulmowski
- Institute of Physics, Faculty of Physics, Astronomy and Informatics, Nicolaus Copernicus University in Toruń, Toruń, Poland
| | - Katarzyna Komar
- Institute of Physics, Faculty of Physics, Astronomy and Informatics, Nicolaus Copernicus University in Toruń, Toruń, Poland.,International Centre for Translational Eye Research, Warsaw, Poland.,Department of Physical Chemistry of Biological Systems, Institute of Physical Chemistry, Polish Academy of Sciences, Kasprzaka 44/52, 01-224 Warsaw, Poland
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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: 0] [Impact Index Per Article: 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.
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Affiliation(s)
- A V Oshorov
- Burdenko Center of Neurosurgery, Moscow, Russia
| | | | | | | | | | - I A Savin
- Burdenko Center of Neurosurgery, Moscow, Russia
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Automated Pupillary Measurements Inversely Correlate With Increased Intracranial Pressure in Pediatric Patients With Acute Brain Injury or Encephalopathy. Pediatr Crit Care Med 2020; 21:753-759. [PMID: 32195898 DOI: 10.1097/pcc.0000000000002327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to determine correlation and temporal association between automated pupillary measurements and intracranial pressure in pediatric patients with brain injury or encephalopathy requiring intracranial pressure monitoring. We hypothesized that abnormal pupillary measurements would precede increases in intracranial pressure. DESIGN A prospective cohort study was performed. Automated pupillometry measurements were obtained at the same frequency as the patients' neurologic assessments with concurrent measurement of intracranial pressure, for up to 72 hours. Pupillary measurements and the Neurologic Pupil index, an algorithmic score that combines measures of pupillary reactivity, were assessed for correlation with concurrent and future intracranial pressure measurements. SETTING Single-center pediatric quaternary ICU, from July 2017 to October 2018. PATIENTS Pediatric patients 18 years or younger with a diagnosis of acute brain injury or encephalopathy requiring an intracranial pressure monitor. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty-eight patients were analyzed with a total of 1,171 intracranial pressure measurements. When intracranial pressure was elevated, the Neurologic Pupil index, percent change in pupillary size, constriction velocity, and dilation velocity were significantly lower than when intracranial pressure was within normal range (p < 0.001 for all). There were mild to moderate negative correlations between concurrent intracranial pressure and pupillary measurements. However, there was an inconsistent pattern of abnormal pupillary measurements preceding increases in intracranial pressure; some patients had a negative association, while others had a positive relationship or no relationship between Neurologic Pupil index and intracranial pressure. CONCLUSIONS Our data indicate automated assessments of pupillary reactivity inversely correlate with intracranial pressure, demonstrating that pupillary reactivity decreases as intracranial pressure increases. However, a temporal association in which abnormal pupillary measurements precede increases in intracranial pressure was not consistently observed. This work contributes to limited data available regarding automated pupillometry in neurocritically ill patients, and the even more restricted subset available in pediatrics.
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Phillips SS, Mueller CM, Nogueira RG, Khalifa YM. A Systematic Review Assessing the Current State of Automated Pupillometry in the NeuroICU. Neurocrit Care 2020; 31:142-161. [PMID: 30484008 DOI: 10.1007/s12028-018-0645-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of this study was to assess the current state of automated pupillometry technology and its application in the neurointensive care unit (neuroICU). We performed a literature search using the PubMed, MEDLINE, and EMBASE databases from database inception through a search end date of October 18, 2018, to identify studies reporting on the use of automated pupillometry in the care of critically ill patients with neurological impairment. Two independent reviewers reviewed all titles and abstracts in two filtering phases. Data were extracted independently. One hundred and forty-one articles/abstracts have been published on the use of automated pupillometry in critical care since inception of the PubMed, MEDLINE, and EMBASE databases. We selected and reviewed 22 full-text articles and 8 abstracts, of which 26 were prospective, 2 were retrospective, and 2 were larger case series. Automated pupillometry increased precision, reliability, and reproducibility compared with the manual pupillary examination; detected subtle and early pupillary changes; detected pupillary changes that indicate a rise, or impending rise, in intracranial pressure detected level of analgesia and depth of sedation; served as a prognostic indicator; estimated the clinical severity of aneurysmal subarachnoid hemorrhage; and served as a noninvasive monitor of response to osmotic therapy. At present, no consensus guidelines exist endorsing routine use of automated pupillometry in the neuroICU. However, an increasing quantity of research supports the usefulness of automated pupillometry in this setting. Further large-scale prospective studies are needed before updated consensus guidelines recommending widespread adoption of automated pupillometry are produced.
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Affiliation(s)
| | | | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Yousuf M Khalifa
- Department of Ophthalmology, Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA, 30307, USA.
- Department of Ophthalmology, Grady Memorial Hospital, Atlanta, GA, USA.
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Automated Pupillometry as an Adjunct to Clinical Examination in Patients With Acute Vision Loss. J Neuroophthalmol 2020; 41:239-245. [PMID: 32235219 DOI: 10.1097/wno.0000000000000919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite automated pupillometry's (AP) improved detection of relative afferent pupillary defects (RAPDs) compared with the Swinging Flashlight Test (SFT), AP remains uncommon in clinical practice. This study examined barriers to routine use of AP in evaluation of acute vision loss. METHODS (1) Ophthalmologists and optometrists' perceptions of AP were captured via electronic survey. (2) Ophthalmologists were presented with clinical vignettes to assess their use of AP in clinical decision-making. (3) Patients presenting with decreased vision to an ophthalmology urgent care clinic underwent manual SFT and AP screening to evaluate ophthalmologists' perceptions of the device. RESULTS Surveys indicated that clinicians were "neutral" to "somewhat likely" to use AP. In clinical vignettes, more physicians proceeded with workup for optic nerve pathology when presented with an RAPD by AP than SFT (77% vs 26%, P = 0.003). When SFT and AP results were discordant, more physicians proceeded with workup for optic nerve disease when AP was positive and SFT was negative than vice versa (61% vs 18%, P = 0.008). In the clinical study of 21 patients, 50% of RAPDs detected by AP were not detected by SFT, although ophthalmologists rated AP's usefulness as only "neutral" to "somewhat useful." CONCLUSION Clinicians value pupillary examination and trust AP over SFT; however, widespread adoption and perceived value of AP may depend on its impact on clinical outcomes. Within a comprehensive diagnostic device, AP may be an important tool, but is not necessary to screen for optic nerve disease or evaluate acute vision loss.
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Neurological Pupil Index as an Indicator of Neurological Worsening in Large Hemispheric Strokes. Neurocrit Care 2020; 33:575-581. [DOI: 10.1007/s12028-020-00936-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Comparison of 2 Automated Pupillometry Devices in Critically III Patients. J Neurosurg Anesthesiol 2019; 32:323-329. [DOI: 10.1097/ana.0000000000000604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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16
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Stevens AR, Su Z, Toman E, Belli A, Davies D. Optical pupillometry in traumatic brain injury: neurological pupil index and its relationship with intracranial pressure through significant event analysis. Brain Inj 2019; 33:1032-1038. [DOI: 10.1080/02699052.2019.1605621] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- A. R. Stevens
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Z. Su
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - E. Toman
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - A. Belli
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - D. Davies
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Correlation of Objective Pupillometry to Midline Shift in Acute Stroke Patients. J Stroke Cerebrovasc Dis 2019; 28:1902-1910. [PMID: 31031146 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.055] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/28/2019] [Accepted: 03/30/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Pupillary dysfunction is recognized as a sign of acute neurological deterioration due to worsening mass effect in patients with hemispheric strokes. Recent neuroimaging studies suggest that horizontal displacement of brain structures may be more important than vertical displacement in explaining these pupillary findings. Pupillometers allow objective and standardized evaluation of the pupillary light reflex. We hypothesized that pupillary data (Neurological Pupil index [NPi] and constriction velocity [CV]) obtained with a hand-held pupilometer, correlate with horizontal intracranial midline shift in patients with ischemic and hemorrhagic strokes. METHODS The ENDPANIC registry is a prospective database of pupillometer readings in neurological patients. There were 134 patients in the database with an acute ischemic stroke or intracerebral hemorrhage who had at least 2 neurologic imaging studies (CT or MRI) and pupillometer assessments performed within 6 hours of the imaging. Horizontal shift of the septum pellucidum (SPS) was measured in 293 images. We computed the correlation between SPS and the following pupillary variables: size, NPi, CV (left, right, and left-right difference), followed by a regression model to control for confounders. RESULTS There were 94 patients (70.1%) with an ischemic stroke and 40 patients (29.9%) had an intracerebral hemorrhage. After controlling for age, race, and gender, there was a significant correlation between the SPS and NPi (left [P < .001], right [P < .001]), CV (left [P < .005], right [P < .001]) pupillary asymmetry (absolute difference between right and left; P < .05), but not between SPS and pupillary size (left or right). There was a significant correlation between the NPi and CV for the right pupil when there was a right-to-left SPS (P < .001 and P < .05, respectively), but none between the NPi and CV for the left pupil and left-to-right SPS. CONCLUSIONS In patients with ischemic and hemorrhagic strokes, there is a significant correlation between SPS and the NPi, CV and pupillary asymmetry, but not with pupillary size.
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Al-Mufti F, Sursal T, Kim M, Menjivar AM, Cole C, Chandy D, Schmidt M, Bowers C, Gandhi CD. Noninvasive Multimodality Cerebral Monitoring Modalities in Neurosurgical Critical Care. World Neurosurg 2018; 121:249-250. [PMID: 30347294 DOI: 10.1016/j.wneu.2018.10.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Tolga Sursal
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Michael Kim
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Alvaro Martin Menjivar
- Department of Internal Medicine - Division of Critical Care, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Chad Cole
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Dipak Chandy
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA; Department of Internal Medicine - Division of Critical Care, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Meic Schmidt
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Christian Bowers
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Chirag D Gandhi
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
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Al-Mufti F, Smith B, Lander M, Damodara N, Nuoman R, El-Ghanem M, Kamal N, Al-Marsoummi S, Alzubaidi B, Nuoaman H, Foreman B, Amuluru K, Gandhi CD. Novel minimally invasive multi-modality monitoring modalities in neurocritical care. J Neurol Sci 2018; 390:184-192. [PMID: 29801883 DOI: 10.1016/j.jns.2018.03.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/14/2018] [Accepted: 03/25/2018] [Indexed: 11/19/2022]
Abstract
Elevated intracranial pressure (ICP) following brain injury contributes to poor outcomes for patients, primarily by reducing the caliber of cerebral vasculature, and thereby reducing cerebral blood flow. Careful monitoring of ICP is critical in these patients in order to determine prognosis, implement treatment when ICP becomes elevated, and to judge responsiveness to treatment. Currently, the gold standard for monitoring is invasive pressure transducers, usually an intraventricular monitor, which presents significant risk of infection and hemorrhage. These risks made discovering non-invasive methods for monitoring ICP and cerebral perfusion a priority for researchers. Herein we sought to review recent publications on novel minimally invasive multi-modality monitoring techniques that provide surrogate data on ICP, cerebral oxygenation, metabolism and blood flow. While limitations in various forms preclude them from supplanting the use of invasive monitors, these modalities represent useful screening tools within our armamentarium that may be invaluable when the risks of invasive monitoring outweigh the associated benefits.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Neurosurgery and Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States; Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States.
| | - Brendan Smith
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Megan Lander
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Nitesh Damodara
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Rolla Nuoman
- Department of Neurology, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Mohammad El-Ghanem
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Naveed Kamal
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Sarmad Al-Marsoummi
- Department of Biomedical Sciences, University of North Dakota, Grand Forks, ND, United States
| | - Basim Alzubaidi
- Department of Neurology, Neurosurgery and Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Halla Nuoaman
- Department of Neurology, Neurosurgery and Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, Division of Neurocritical Care, University of Cincinnati, Cincinnati, OH, United States
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh, Hamot, Erie, PA, United States
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center - New York Medical College, Valhalla, NY, United States
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Lee MH, Mitra B, Pui JK, Fitzgerald M. The use and uptake of pupillometers in the Intensive Care Unit. Aust Crit Care 2017; 31:199-203. [PMID: 28728875 DOI: 10.1016/j.aucc.2017.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 03/23/2017] [Accepted: 06/16/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a significant public health issue. Assessing pupil reactivity is a crucial aspect of its management and the pupillometer has been shown to be a more objective tool compared to the standard penlight. Its use, however, is not widespread. OBJECTIVE To investigate the paucity in uptake, we examined the frequency of use of pupillometers (NeurOptics®NPi-100™) amongst Intensive Care Unit (ICU) doctors and nurses, evaluated its user-friendliness and explored barriers to its use. DESIGN An online cross-sectional survey. METHODS Surveys were distributed five months after the introduction of pupillometers (in May 2015) to ICU doctors and nurses working in a quaternary referral centre providing state services for trauma. The survey included sections on: questions on demographics and experience, methods of conventional pupillary assessment in patients with TBI, experience of using the pupillometer, and questions on barriers to its use. Responses were collated as discrete variables and summarised using counts and proportions. Comparisons among proportions were undertaken using the chi-squared test and reported with 95% confidence intervals. RESULTS A total of 79 responses were recorded, predominantly 94.9% (n=75) from nursing staff. A total of 50 (63.3%) responders were using the pupillometers, with a mean frequency-of-use rating of 4.67 out of 10 and a mean user-friendliness rating of 6.28 out of 10. There was no association between frequency of use and user-friendliness (p=0.36). The main identified barriers to its use included a lack of education with regards to its use, a perceived lack of clinical significance, a lack of standardisation of documenting findings, and difficulties with access to disposable patient shields (Smartguards). CONCLUSIONS There was good adoption of the technology in the early phases of ICU implementation with user-friendliness rated favourably. In this paper we identify barriers to use and discuss possible solutions to increase clinical utility.
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Affiliation(s)
| | - Biswadev Mitra
- Alfred Health, 55 Commercial Road, Melbourne, Australia; National Trauma Research Institute, 85-89 Commercial Road, Melbourne, Australia.
| | - Jiun Kae Pui
- Alfred Health, 55 Commercial Road, Melbourne, Australia.
| | - Mark Fitzgerald
- Alfred Health, 55 Commercial Road, Melbourne, Australia; National Trauma Research Institute, 85-89 Commercial Road, Melbourne, Australia.
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