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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.
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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
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Aoun SG, Welch BG, Cortes M, Stutzman SE, MacAllister MC, El Ahmadieh TY, Osman M, Figueroa SA, White JA, Batjer HH, Olson DM. Objective Pupillometry as an Adjunct to Prediction and Assessment for Oculomotor Nerve Injury and Recovery: Potential for Practical Applications. World Neurosurg 2018; 121:e475-e480. [PMID: 30267943 DOI: 10.1016/j.wneu.2018.09.140] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pupillary light reflex examinations are intrinsic to any good neurological examination. Consistent evidence has shown that automated pupillometry assessments provide superior accuracy and interrater correlation compared with bedside eye examinations. Pupillary indexes such as the neurological pupil index (NPI) can also provide several hours of warning before the advent of herniation syndromes or third nerve palsy. METHODS We determined the unique temporal relationship between NPI changes and third nerve palsy occurrence and recovery in an initially neurologically intact hospitalized patient. A 53-year-old woman presented with aneurysmal subarachnoid hemorrhage and headaches. Her aneurysm was treated surgically without complications. After lumbar drainage for hydrocephalus, she developed isolated left third nerve palsy that slowly recovered over the following weeks. Pupilometer data were obtained throughout her hospital stay. RESULTS A total of 121 pupillary measurement sets were obtained. The NPI had decreased to an abnormal level (<3) 12 hours before she became symptomatic. The NPI also started improving 24 hours before improvement in her clinical examination. The patient did not display signs of neurological dysfunction related to vasospasm during her stay. CONCLUSION The NPI seems to reliably correlate with third nerve function and appears to possess predictive temporal properties that could allow practitioners to anticipate neurological injury and recovery. These findings could affect the fields of neurosciences, trauma, military medicine, critical care, and ophthalmology.
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Affiliation(s)
- Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA.
| | - Babu G Welch
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA
| | - Michaela Cortes
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA
| | - Sonja E Stutzman
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Houston, Texas, USA; Division of Neurocritical Care, University of Texas Southwestern Medical Center, Houston, Texas, USA
| | - Matthew C MacAllister
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA
| | - Mohamed Osman
- Division of Neurocritical Care, University of Texas Southwestern Medical Center, Houston, Texas, USA
| | - Stephen A Figueroa
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA; Division of Neurocritical Care, University of Texas Southwestern Medical Center, Houston, Texas, USA
| | - Jonathan A White
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA
| | - Hunt H Batjer
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA
| | - Daiwai M Olson
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Houston, Texas, USA; Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Houston, Texas, USA
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