Dexmedetomidine and Other Analgosedatives Alter Pupil Characteristics in Critically Ill Patients

Chan, Wang Pong; Prescott, Brenton; Barra, Megan E.; Chung, David Y.; Kim, Ivy S.; Saglam, Hanife; Hutch, Meghan R.; Shin, Min Chul; Zafar, Sahar F.; Benjamin, Emelia J.; Smirnakis, Stelios M.; Dupuis, Josée; Greer, David M.; Ong, Charlene

doi:10.1097/cce.0000000000000691

Cited by 11 publications

(2 citation statements)

References 42 publications

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“…We did not have information on cognitive load, pain, or ambient light levels, which have been reported to affect pupil characteristics ( 14 ). We were unable to adjust for all potential residual confounders including potential pupil influencing medications ( 15 , 30 ), which can affect pupil size and reactivity. However, we have included data that occurred prior to pupil measurments and prior to imaging in Supplementary Table 3 .…”

Section: Discussionmentioning

confidence: 99%

Quantitative pupillometry and radiographic markers of intracranial midline shift: A pilot study

et al. 2022

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BackgroundAsymmetric pupil reactivity or size can be early clinical indicators of midbrain compression due to supratentorial ischemic stroke or primary intraparenchymal hemorrhage (IPH). Radiographic midline shift is associated with worse functional outcomes and life-saving interventions. Better understanding of quantitative pupil characteristics would be a non–invasive, safe, and cost-effective way to improve identification of life-threatening mass effect and resource utilization of emergent radiographic imaging. We aimed to better characterize the association between midline shift at various anatomic levels and quantitative pupil characteristics.MethodsWe conducted a multicenter retrospective study of brain CT images within 75 min of a quantitative pupil observation from patients admitted to Neuro-ICUs between 2016 and 2020 with large (>1/3 of the middle cerebral artery territory) acute supratentorial ischemic stroke or primary IPH > 30 mm3. For each image, we measured midline shift at the septum pellucidum (MLS-SP), pineal gland shift (PGS), the ratio of the ipsilateral to contralateral midbrain width (IMW/CMW), and other exploratory markers of radiographic shift/compression. Pupil reactivity was measured using an automated infrared pupillometer (NeurOptics®, Inc.), specifically the proprietary algorithm for Neurological Pupil Index® (NPi). We used rank-normalization and linear mixed-effects models, stratified by diagnosis and hemorrhagic conversion, to test associations of radiographic markers of shift and asymmetric pupil reactivity (Diff NPi), adjusting for age, lesion volume, Glasgow Coma Scale, and osmotic medications.ResultsOf 53 patients with 74 CT images, 26 (49.1%) were female, and median age was 67 years. MLS-SP and PGS were greater in patients with IPH, compared to patients with ischemic stroke (6.2 v. 4.0 mm, 5.6 v. 3.4 mm, respectively). We found no significant associations between pupil reactivity and the radiographic markers of shift when adjusting for confounders. However, we found potentially relevant relationships between MLS-SP and Diff NPi in our IPH cohort (β = 0.11, SE 0.04, P = 0.01), and PGS and Diff NPi in the ischemic stroke cohort (β = 0.16, SE 0.09, P = 0.07).ConclusionWe found the relationship between midline shift and asymmetric pupil reactivity may differ between IPH and ischemic stroke. Our study may serve as necessary preliminary data to guide further prospective investigation into how clinical manifestations of radiographic midline shift differ by diagnosis and proximity to the midbrain.

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confidence: 99%

Quantitative pupillometry and radiographic markers of intracranial midline shift: A pilot study

et al. 2022

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“…Notably, the NPi is minimally influenced by sedation than the other directly measured pupillometric variables, and it has therefore been more often reported in critical care studies. 4,5 A prospective, observational, multicenter cohort study on more than 500 patients demonstrated that NPi has a significant prognostic value for neurological outcome and mortality after acute brain injury, not influenced by sedation, and its assessment could describe the dynamics of outcome prediction at the bedside. 6 In conclusion, I would like to highlight the importance of conducting a more comprehensive investigation into the impact of sedation on pupillary responses.…”

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Evaluating a Pupillometry App Considering Sedation's Impact: A Step Unexplored

Zanier,

Citerio

2024

Journal of Neurotrauma

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Neurological Pupil Index and Intracranial Hypertension in Patients With Acute Brain Injury

Petrosino,

Gouvêa Bogossian,

Rebora

et al. 2024

JAMA Neurol

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ImportanceInvasive intracranial pressure (ICP) is the standard of care in patients with acute brain injury (ABI) with impaired consciousness. The Neurological Pupil Index (NPi) obtained by automated pupillometry is promising for noninvasively estimating ICP.ObjectivesTo evaluate the association between repeated NPi and invasive ICP values.Design, Setting, and ParticipantsThis study is a secondary analysis of the Outcome Prognostication of Acute Brain Injury With the Neurological Pupil Index (ORANGE), a multicenter, prospective, observational study of patients with ABI performed from October 1, 2020, to May 31, 2022, with follow-up at 6 months after ABI. The ORANGE study was performed at neurologic intensive care units of tertiary hospitals in Europe and North America. In ORANGE, 514 adult patients receiving mechanical ventilatory support were admitted to the intensive care unit after ABI.ExposureInvasive ICP monitoring and automated pupillometry assessment every 4 hours during the first 7 days, considered as a standard of care.Main Outcomes and MeasuresAssociation between ICP and NPi values over time, using bayesian joint models, with linear and logistic mixed-effects longitudinal submodels.ResultsThe study included 318 adult patients (median [IQR] age, 58 [43-69] years; 187 [58.8%] male) who required intensive care unit admission, intubation, and mechanical ventilatory support due to acute traumatic brain injury (n = 133 [41.8%]), intracerebral hemorrhage (n = 104 [32.7%]), or aneurysmal subarachnoid hemorrhage (n = 81 [25.5%]) and had automatic infrared pupillometry used as part of the standard evaluation practice and ICP monitoring. A total of 8692 ICP measurements were collected, with a median (IQR) of 31 (18-37) evaluations per patient. The median (IQR) NPi and ICP for the study population were 4.1 (3.5-4.5) and 10 (5-14) mm Hg, respectively. In a linear mixed model, the mean change in the NPi value, as a continuous variable, was −0.003 (95% credible interval [CrI], −0.006 to 0.000) for each 1-mm Hg ICP increase. No significant association between ICP and abnormal NPi (&lt;3; odds ratio, 1.01; 95% CrI, 0.99-1.03) or absent NPi (0; odds ratio, 1.03; 95% CrI, 0.99-1.06) was observed.Conclusions and RelevanceAlthough an abnormal NPi could indicate brainstem dysfunction, in this large and heterogeneous population of patients, NPi values were not significantly associated overall with ICP values. Repeated NPi measurements may not be a sufficient replacement for invasive monitoring.Trial RegistrationClinicalTrials.gov Identifier: NCT04490005

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Dexmedetomidine and Other Analgosedatives Alter Pupil Characteristics in Critically Ill Patients

Cited by 11 publications

References 42 publications

Quantitative pupillometry and radiographic markers of intracranial midline shift: A pilot study

Quantitative pupillometry and radiographic markers of intracranial midline shift: A pilot study

Evaluating a Pupillometry App Considering Sedation's Impact: A Step Unexplored

Neurological Pupil Index and Intracranial Hypertension in Patients With Acute Brain Injury

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