Neuromonitoring of delirium with quantitative pupillometry In sedated mechanically ventilated critically ill patients

Favre, E.; Bernini, Adriano; Morelli, Paola; Pasquier, Jérôme; Miroz, John‐Paul; Abed-Maillard, Samia; Ben-Hamouda, Nawfel; Oddo, Mauro

doi:10.21203/rs.2.19734/v2

Cited by 3 publications

(5 citation statements)

References 23 publications

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“…As such, sepsis is frequently associated with brain dysfunction and impairment of cerebral autoregulation [12]. Few data are available on alterations in pupillary response using the automated pupillometry in these patients [48]; however, common pathways in brain and pupillary dysfunction, in particular of the cholinergic pathways, have been described in sepsis and might explain why we could observe a significant correlation only in this subgroup of patients. Nevertheless, the correlation was weak, as additional factors, such as sedative or analgesics, may significantly influence pupillary function in this setting as additional confounders [18,19].…”

Section: Discussionmentioning

confidence: 84%

The use of automated pupillometry to assess cerebral autoregulation: a retrospective study

et al. 2020

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Background: Critically ill patients are at high risk of developing neurological complications. Among all the potential aetiologies, brain hypoperfusion has been advocated as one of the potential mechanisms. Impairment of cerebral autoregulation (CAR) can result in brain hypoperfusion. However, assessment of CAR is difficult at bedside. We aimed to evaluate whether the automated pupillometer might be able to detect impaired CAR in critically ill patients. Methods: We included 92 patients in this retrospective observational study; 52 were septic. CAR was assessed using the Mxa index, which is the correlation index between continuous recording of cerebral blood flow velocities using the transcranial Doppler and invasive arterial blood pressure over 8 ± 2 min. Impaired CAR was defined as an Mxa > 0.3. Automated pupillometer (Neuroptics, Irvine, CA, USA) was used to assess the pupillary light reflex concomitantly to the CAR assessment. Results: The median Mxa was 0.33 in the whole cohort (0.33 in septic patients and 0.31 in the non-septic patients; p = 0.77). A total of 51 (55%) patients showed impaired CAR, 28 (54%) in the septic group and 23 (58%) in the non-septic group. We found a statistically significant although weak correlation between Mxa and the Neurologic Pupil Index (r 2 = 0.04; p = 0.048) in the whole cohort as in septic patients (r 2 = 0.11; p = 0.026); no correlation was observed in non-septic patients and for other pupillometry-derived variables. Conclusions: Automated pupillometry cannot predict CAR indices such as Mxa in a heterogeneous population of critically ill patients.

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Section: Discussionmentioning

confidence: 84%

The use of automated pupillometry to assess cerebral autoregulation: a retrospective study

et al. 2020

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“…The rate of delirium was recently estimated at 59% in critically ill patients without COVID-19 in our hospital. 27 Conversely, previous studies 8,9 available at the initiation of this project reported delirium rates over 80% in patients with COVID-19. We originally estimated a 2-sided α level of 0.05 and power of 80% to detect an absolute increase of 22% in the delirium incidence in patients with COVID-19; assuming an incidence of 60% in the control group and a 4:1 inclusion ratio (COVID-19:non-COVID-19), at least 180 patients including 144 with COVID-19 vs 36 without COVID-19 were to be enrolled.…”

Section: Discussionmentioning

confidence: 76%

“…Patients were considered delirious if they had at least 1 positive CAM-ICU, as in previous studies. 8,27,28 We also analyzed delirium length by retrieving the number of days with at least 1 positive CAM-ICU. Yet, these data were censored when the patients were discharged from the ICU.…”

Section: Outcome Variablesmentioning

confidence: 99%

Delirium in Adults With COVID-19–Related Acute Respiratory Distress Syndrome

et al. 2022

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Background and objectives:Neurological complications have been associated with COVID-19, including deliriumSuch complications have been reported to be frequent among ICU admitted patients. We hypothesized that the rate of neurological complications would be higher in COVID-19 associated acute respiratory distress syndrome (ARDS) than those who develop ARDS from a different cause.Methods:We conducted a retrospective cohort study in the adult intensive care unit (ICU) of our hospital, including all consecutive patients fulfilling Berlin criteria for ARDS hospitalized between December 2017 and June 2021, stratifying exposure between COVID-19 or not. The primary outcome was delirium onset during ICU stay, defined by the confusion assessment method (CAM-ICU). Exploratory outcomes included development of neurological complications of the central (stroke, hemmorhage, vasculitis) or critical illness weakness, and 30 and 180 days all-cause mortality.Results:311 patients were included in the study (253 with COVID-19 and 58 with other causes); CAM-ICU was assessed in 231 (74.3% in COVID-19 vs. 74,1% in non-COVID-19). The proportion of patients developing delirium was similar in patients with COVID-19 and controls in univariate comparison(69.1% vs 60.5%, P=0.246). Yet, COVID-19 patients had higher body mass index, lower ICU severity, longer mechanical ventilation, and higher sedation doses (propofol, dexmedetomidine). After adjusting for these factors in COVID-19 patients in a multivariable analysis, the risk of delirium remained comparable across groups (adjusted odds ratio (OR) (95% CI): 0.86 (0.35-2.1)). Similarly, COVID-19 related ARDS had no impact on all-cause mortality at 30 days (adjusted OR: 0.87 (0.39-1.92)) and 180 days (adjusted OR: 0.67 (0.33-1.35)). Finally, neurological complications affecting the central nervous system (adjusted OR: 1.15 (0.25-5.29)) and critical illness weakness (adjusted OR: 2.99 (0.97-9.1)) were not higher in the COVID-19 group.Discussion: Compared to other etiologies, patients with COVID-19 did not have higher incidence of delirium and other neurological complications, after accounting for underlying disease severity in ARDS patients. Management of COVID-19 associated ARDS needed longer invasive ventilation and higher sedation, which could explain higher rates of delirium in uncontrolled studies.

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“…The use of AIP for evaluating patients in both psychiatric and neurological settings extensively studied and has been used to predict outcomes after subarachnoid hemorrhage or cardiac arrest (Natzeder et al, 2019; Riker et al, 2020; Tamura et al, 2020). Recent studies have examined the relationship between CAM ICU scores and AIP indices (Favre et al, 2020; Yang et al, 2018). However, no study has investigated the relationship between the ICDSC score and AIP parameters.…”

Section: Review Of Literaturementioning

confidence: 99%

“…The quantitative measurement of the pupillary light reflex by AIP represents an attractive tool for evaluating cholinergic activity in a clinical setting (Bower et al, 2021). In recent years, AIP has been suggested as an effective method for the early detection of delirium (Favre et al, 2020; Yang et al, 2018). Therefore, we hypothesized that AIP at ICU admission could predict the severity of delirium during the ICU stay.…”

Section: Introductionmentioning

confidence: 99%

Use of Automated Infrared Pupillometry to Predict Delirium in the Intensive Care Unit: A Prospective Observational Study

et al. 2022

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Introduction Delirium is an acute state of brain dysfunction prevalent among critically ill patients. Disturbances in the sympathetic neurons, including cholinergic neurons, have been reported to cause delirium by upsetting the balance of neurotransmitter synthesis, release, and inactivation. The cholinergic system mediates pupillary constriction as a response to light stimulation, and this reflex can be measured using automated infrared pupillometry (AIP). The relationship between delirium and AIP parameters has been examined. The Confusion Assessment Method for the Intensive Care Unit (CAM ICU) and the Intensive Care Unit Delirium Screening Checklist (ICDSC) are used for assessing delirium. However, that between the ICDSC score and AIP parameters remains unclear. Objective To examine the relationship between AIP parameters and the various categories of delirium as defined by the ICDSC score (delirium, subsyndromal delirium, no delirium). Methods This prospective observational study included patients aged ≥18 years admitted to the intensive care unit (ICU) from May 2018 to September 2018. ICU patients were classified into delirium, subsyndromal delirium, and no delirium groups according to the ICDSC score during ICU stay. The pupillary light reflex was assessed in both eyes immediately after admission using AIP with a portable infrared pupillometer. Logistic regression analyses were used to estimate the odds ratio to examine the relationship between the severity of delirium as assessed by the ICDSC score and the AIP parameters. Results In total 133 patients were included in the study. Based on the ICDSC scores, 41.4% of patients had no delirium, 40.6% had subsyndromal delirium, and 18% had delirium. Dilation velocity (DV) measured by AIP was significantly different among the delirium, subsyndromal delirium, and no delirium groups. Post-hoc comparisons showed that DV was significantly slower in the delirium group than in the no delirium group but was not significantly different between the subsyndromal delirium and no delirium groups. After adjusting for patients’ sex and age at enrollment, DV was shown to be independently associated with delirium. Conclusion This study suggests that the use of AIP at ICU admission may improve the identification of patients at a high risk of developing delirium.

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Neuromonitoring of delirium with quantitative pupillometry In sedated mechanically ventilated critically ill patients

Cited by 3 publications

References 23 publications

The use of automated pupillometry to assess cerebral autoregulation: a retrospective study

The use of automated pupillometry to assess cerebral autoregulation: a retrospective study

Delirium in Adults With COVID-19–Related Acute Respiratory Distress Syndrome

Use of Automated Infrared Pupillometry to Predict Delirium in the Intensive Care Unit: A Prospective Observational Study

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