The effects of anesthetic agents on pupillary function during general anesthesia using the automated infrared quantitative pupillometer

Shirozu, Kazuhiro; Setoguchi, Hidekazu; Tokuda, Kentaro; Karashima, Yuji; Ikeda, Makoto; Kubo, Makoto; Nakamura, Katsuya; Hoka, Sumio

doi:10.1007/s10877-016-9839-3

Cited by 54 publications

(45 citation statements)

References 16 publications

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“…High-dose propofol [29] also may potentially reduce the NPi; however, the infusion dose of propofol was kept < 4 mg/kg in our study. It was shown by Delfino et al that infused propofol at 100 μg/kg/min (= 6 mg/kg/h) resulted in bispectral index (BIS) monitoring values of approximately 42 [30], and indeed, at this infusion rate, propofol has no effect on the NPi (while it significantly reduced pupil size and percentage constriction) [31]. Finally, it is worth noting that the NPi value is adjusted to individual resting pupil size [32].…”

Section: Discussionmentioning

confidence: 99%

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

et al. 2019

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Background: Elevated intracranial pressure (ICP) is frequent after traumatic brain injury (TBI) and may cause abnormal pupillary reactivity, which in turn is associated with a worse prognosis. Using automated infrared pupillometry, we examined the relationship between the Neurological Pupil index (NPi) and invasive ICP in patients with severe TBI. Methods: This was an observational cohort of consecutive subjects with severe TBI (Glasgow Coma Scale [GCS] < 9 with abnormal lesions on head CT) who underwent parenchymal ICP monitoring and repeated NPi assessment with the NPi-200® pupillometer. We examined NPi trends over time (four consecutive measurements over intervals of 6 h) prior to sustained elevated ICP > 20 mmHg. We further analyzed the relationship of cumulative abnormal NPi burden (%NPi values < 3 during total ICP monitoring time) with intracranial hypertension (ICHT)-categorized as refractory (ICHT-r; requiring surgical decompression) vs. non-refractory (ICHT-nr; responsive to medical therapy)-and with the 6-month Glasgow Outcome Score (GOS). Results: A total of 54 patients were studied (mean age 54 ± 21 years, 74% with focal injuries on CT), of whom 32 (59%) had ICHT. Among subjects with ICHT, episodes of sustained elevated ICP (n = 43, 172 matched ICP-NPi samples; baseline ICP [T − 6 h ] 14 ± 5 mmHg vs. ICPmax [T 0 h ] 30 ± 9 mmHg) were associated with a concomitant decrease of the NPi (baseline 4.2 ± 0.5 vs. 2.8 ± 1.6, p < 0.0001 ANOVA for repeated measures). Abnormal NPi values were more frequent in patients with ICHT-r (n = 17; 38 [3-96]% of monitored time vs. 1 [0-9]% in patients with ICHT-nr [n = 15] and 0.5 [0-10]% in those without ICHT [n = 22]; p = 0.007) and were associated with an unfavorable 6-month outcome (15 [1-80]% in GOS 1-3 vs. 0 [0-7]% in GOS 4-5 patients; p = 0.002). Conclusions: In a selected cohort of severe TBI patients with abnormal head CT lesions and predominantly focal cerebral injury, elevated ICP episodes correlated with a concomitant decrease of NPi. Sustained abnormal NPi was in turn associated with a more complicated ICP course and worse outcome.

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Section: Discussionmentioning

confidence: 99%

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

et al. 2019

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“…Second, concurrent use of drugs that could confound the evaluation of the PLR such as opioids, anticholinergics, or sedative agents was not evaluated. Although a previous study showed that the use of these medications within therapeutic doses does not signi cantly suppress the PLR [38], we cannot exclude the possibility that other medications such as propofol may have affected the PLR [39]. Third, we did not analyze confounders such as underlying pathology of the retina or optic nerve as well as the in uence of ambient lights on the PLR [40].…”

Section: Discussionmentioning

confidence: 99%

Quantitative Assessments of Pupillary Light Reflexes in Hospital-Onset Unconsciousness

Lee

Choi

Park

et al. 2020

Preprint

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BackgroundPatients who develop hospital-onset unconsciousness should be promptly managed in order to avoid clinical deterioration. Pupillary examination through pupillary light reflex is the mainstay method in the initial evaluation of unconscious patients, but the current method of light shedding and subjective description often shows poor reliability. The objective of this study is to explore whether a quantitative measurement of pupillary light reflexes is useful in detecting brain herniation syndrome and predicting neurological outcomes in non-neurological patients who developed hospital-onset unconsciousness.MethodsThis was a registry-based observational study on patients who activated the neurological rapid response team at Asan Medical Center (Seoul, Korea). Hospital-onset unconsciousness was defined as a newly developed stupor or comatose state during admission. Demographics, comorbidities, pupillometry parameters including Neurological Pupil index, brain herniation syndrome, in-hospital mortality, and modified Rankin Scale at 3-months were analyzed.ResultsIn 214 consecutive patients with hospital-onset unconsciousness, 37 (17%) had brain herniation syndrome. The optimal cut-off value of Neurological Pupil index for detecting brain herniation syndrome was < 1.6 (specificity, 91% [95% confidence interval (CI) = 86−95]; sensitivity, 49% [95% CI = 32−66]). The in-hospital mortality rate was 28% (59/214); the Neurological Pupil index was negatively associated with in-hospital mortality after adjustments for the presence of brain herniation syndrome (adjusted odds ratio = 0.77, 95% CI = 0.62–0.96). Poor neurological outcomes (modified Rankin Scale ≥ 4) at 3 months was observed in 76% (152/201) of the patients; the Neurological Pupil index was negatively associated with poor neurological outcomes after adjustments for clinical variables (adjusted odds ratio = 0.67, 95% CI = 0.49–0.90). ConclusionsQuantitative measurements of pupillary light reflexes may be useful for early detection of potentially life-threatening neurological conditions in patients with hospital-onset unconsciousness.

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“…18,19 One recent study established that fentanyl decreased pupil size and altered pupil light reactivity but did not change the NPi. 18 Another study observed transient, symmetrical CV reductions in an outpatient population after administration of narcotics (oral or IV) and benzodiazepines.…”

Section: Discussionmentioning

confidence: 99%

Are There Predictive Pupillometry Markers in Determining External Ventricular Device (EVD) Weaning Failure or Success in Subarachnoid Hemorrhage Patients?

Bezner¹,

Nattanmai²,

Katyal³

et al. 2018

Am J Hosp Med

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Introduction: Pupillometers objectively measure constriction (i.e., parasympathetic pathway) and dilation (i.e., sympathetic pathway) velocities of the pupillary reflex. These pathways may be affected by increases in ventricular size due to changes in cerebrospinal fluid (CSF) volume, such as during external ventricular device (EVD) weaning in aneurysmal subarachnoid hemorrhage (aSAH) patients. This pilot study evaluated if changes in pupillary responses could be predictive of EVD weaning failure in aSAH patients. Additionally, we analyzed ventricular size and pupillary reactions in these two groups. Methods: Adult aSAH patients serially monitored with the pupillometer at an academic medical center were included. Patients were grouped into those successfully weaned from the EVD and those who were not. Pupillometer measurements (e.g. changes in constriction and dilation velocities), changes in intracranial pressure (ICP), changes in cerebral aqueduct diameter and 3 rd ventricle diameter (measured via computed tomography head (CTH)) were evaluated between the two groups. Results: Seven patients met the inclusion criteria. Three patients required ventriculoperitoneal shunting. There were no significant differences in the changes in constriction or dilation velocities between the groups. Additionally, there was no significant difference in ICP. There were significant differences between the changes in size of the cerebral aqueduct (p=0.01) and of the third ventricle (p=0.01) on CTH between those who weaned and those who did not. These did not correlate with pupillometer measurements. Conclusions: We did not find predictive value in changes in constriction or dilation velocities or ICP on EVD weaning success in aSAH patients. Changes in the diameter of the third ventricle or cerebral aqueduct may be predictive of EVD weaning and suggests a further avenue for study.

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The effects of anesthetic agents on pupillary function during general anesthesia using the automated infrared quantitative pupillometer

Cited by 54 publications

References 16 publications

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury

Quantitative Assessments of Pupillary Light Reflexes in Hospital-Onset Unconsciousness

Are There Predictive Pupillometry Markers in Determining External Ventricular Device (EVD) Weaning Failure or Success in Subarachnoid Hemorrhage Patients?

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