Skip to main content

Advertisement

SpringerLink
Log in

Neurological Pupil Index and Pupillary Light Reflex by Pupillometry Predict Outcome Early After Cardiac Arrest

  • Original Work
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Background

The absence of the pupillary light reflex (PLR) 3 days after cardiac arrest predicts poor outcome, but quantitative PLR assessment with pupillometry early after recovery of spontaneous circulation (ROSC) and throughout targeted temperature management (TTM) has rarely been evaluated.

Methods

Fifty-five adult patients treated with TTM with available pupillometry data from the NeurOptics NPi-200 were studied. Discharge outcome was classified good if the cerebral performance category score was 1–2, poor if 3–5. Pupil size, PLR percent constriction (%PLR), and constriction velocity (CV) were determined at TTM start and 6 (± 2)-h post-ROSC (“early”), and throughout TTM using data from the worst eye at each assessment. The Neurological Pupil index (NPi) was also determined at each pupil assessment; the NPi is scored from 0 (nonreactive) to 5 (brisk) with values < 3 considered sluggish or abnormal. Prognostic performance to predict poor outcome was assessed with receiver operator characteristic curves.

Results

All nine patients with ≥ 1 nonreactive pupil (NPi = 0) within 6 (± 2) h after ROSC died, and 12/14 (86%) with sluggish pupils (0 < NPi < 3) had poor outcomes. 15/29 (52%) patients with normal pupil reactivity (NPi ≥ 3) had poor outcomes, four survived with cerebral performance category = 3, three died of cardiac causes, and eight died of neurologic causes. During TTM, 20/21 (95%) patients with nonreactive pupils had poor outcomes, 9/14 (64%) of patients with sluggish pupils had poor outcomes, and 9/20 (45%) with normal pupil reactivity had poor outcomes. Pupil size did not predict outcome, but NPi (AUC = 0.72 [0.59–0.86], p < 0.001), %PLR (AUC = 0.75 [0.62–0.88], p < 0.001) and CV (AUC = 0.78 [0.66–0.91], p < 0.001) at 6 h predicted poor outcome. When nonreactive pupils were first detected, 75% were < 5 mm.

Conclusions

Very early after resuscitation from cardiac arrest, abnormal Neurological Pupil index and pupillary light reflex measurements by pupillometer are predictive of poor outcome, and are not usually associated with dilated pupils.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Stevens RD, Sutter R. Prognosis in severe brain injury. Crit Care Med. 2013;11:1104–23.

    Article  Google Scholar 

  2. Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S. Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: Prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;67:203–10.

    Article  CAS  Google Scholar 

  3. Booth CM, Boone RH, Tomlinson G, Detsky AS. Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest. JAMA. 2004;291:870–9.

    Article  CAS  Google Scholar 

  4. Soar J, Callaway CW, Aibiki M, et al. Part 4: advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Resuscitation. 2015;95:e71–120.

    Article  Google Scholar 

  5. Greer DM, Yang J, Scripko PD, et al. Clinical examination for outcome prediction in nontraumatic coma. Crit Care Med. 2012;40:1150–6.

    Article  Google Scholar 

  6. Chen JW, Vakil-Gilani K, Williamson KL, Cecil S. Infrared pupillometry, the Neurological Pupil index and unilateral pupillary dilation after traumatic brain injury: implications for treatment paradigms. SpringerPlus. 2014;3:548.

    Article  Google Scholar 

  7. Suys T, Bouzat P, Marques-Vidal P, et al. Automated quantitative pupillometry for the prognostication of coma after cardiac arrest. Neurocrit Care. 2014;21:300–8.

    Article  Google Scholar 

  8. Solari D, Rossetti AO, Carteron L, et al. Early prediction of coma recovery after cardiac arrest with blinded pupillometry. Ann Neurol. 2017;81:804–10.

    Article  Google Scholar 

  9. Heimburger D, Durand M, Gaide-Chevronnay L, et al. Quantitative pupillometry and transcranial Doppler measurements in patients treated with hypothermia after cardiac arrest. Resuscitation. 2016;103:88–93.

    Article  Google Scholar 

  10. Behrends M, Niemann CU, Larson MD. Infrared pupillometry to detect the light reflex during cardiopulmonary resuscitation:a case series. Resuscitation. 2012;83:1223–8.

    Article  Google Scholar 

  11. Tamura T, Namiki J, Sugawara Y, et al. Quantitative assessment of pupillary light reflex for early prediction of outcomes after out-of-hospital cardiac arrest: a multicentre prospective observational study. Resuscitation. 2018;131:108–13.

    Article  Google Scholar 

  12. Oddo M, Sandroni C, Citerio G, et al. Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blind study. Intensive Care Med. 2018;44:2102–11.

    Article  Google Scholar 

  13. Larson MD, Behrends M. Portable infrared pupillometry: a review. Anesth Analg. 2015;120(6):1242–53.

    Article  Google Scholar 

  14. May TL, Seder DB, Fraser GL, Stone P, McCrum B, Riker RR. Moderate-dose sedation and analgesia during targeted temperature management after cardiac arrest. Neurocrit Care. 2015;22:105–11.

    Article  CAS  Google Scholar 

  15. Riker RR, Gagnon DJ, May T, Seder DB, Fraser GL. Analgesia, sedation, and neuromuscular blockade during targeted temperature management after cardiac arrest. Best Pract Res Clin Anaesthesiol. 2015;29:435–50.

    Article  Google Scholar 

  16. Monsieurs KG, Nolan JP, Bossaert LL, et al. European resuscitation council guidelines for resuscitation 2015 section 1. Executive summary. Resuscitation. 2015;95:1–80.

    Article  Google Scholar 

  17. Olson DM, Fishel M. The use of automated pupillometry in critical care. Crit Care Nurs Clin N Am. 2016;28:101–7.

    Article  Google Scholar 

  18. Olson DM, Stutzman S, Saju C, Wilson M, Zhao W, Aiyagari V. Interrater reliability of pupillary assessments. Neurocrit Care. 2016;24:251–7.

    Article  Google Scholar 

  19. Perkins NJ, Schisterman EF. The inconsistency of “optimal” cutpoints obtained using two criteria based on the receiver operating characteristic curve. Am J Epidemiol. 2006;163:670–5.

    Article  Google Scholar 

  20. Bossuyt PM, Reitsma JB, Bruns DE, et al. STARD 2015: an updated list of essential items for reporting diagnostic accuracy studies. BMJ. 2015;351:h5527.

    Article  Google Scholar 

  21. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;21(346):549–56.

    Google Scholar 

  22. Couret D, Boumaza D, Grisotto C, et al. Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study. Crit Care. 2016;20:99.

    Article  Google Scholar 

  23. NeurOptics NPi®-200 Pupillometer instructions for use. https://neuroptics.com/wp-content/uploads/2019/01/NPi2_IFU_HOMA-956RTQ-revJ_V10. Accessed 6 March 2019.

  24. Larson MD, Sessler DI, McGuire J, Hynson JM. Isoflurane, but not mild hypothermia, depresses the human pupillary light reflex. Anesthesiology. 1991;75(1):62–7.

    Article  CAS  Google Scholar 

  25. Larson MD, O’Donnell BR, Merrifield BF. Ocular hypothermia depresses the human pupillary light reflex. Invest Ophthalmol Vis Sci. 1991;32(13):3285–7.

    CAS  PubMed  Google Scholar 

  26. Belani KG, Sessler DI, Larson MD, et al. The pupillary light reflex. Effects of anesthetics and hyperthermia. Anesthesiology. 1993;79:23–7.

    Article  CAS  Google Scholar 

  27. Shirozu K, Setoguchi H, Tokuda K, et al. The effects of anesthetic agents on pupillary function during general anesthesia using the automated infrared quantitative pupillometer. J Clin Monit Comput. 2017;31:291–6.

    Article  Google Scholar 

  28. Snyder BD, Gumnit RJ, Leppik IE, Hauser WA, Loewenson RB, Ramirez-Lassepas M. Neurologic prognosis after cardiopulmonary arrest: IV. Brainstem reflexes. Neurology. 1981;31:1092–7.

    Article  CAS  Google Scholar 

  29. Levy DE, Caronna JJ, Singer BH, Lapinski RH, Frydman H, Plum F. Predicting outcome from hypoxic-ischemic coma. JAMA. 1985;253:1420–6.

    Article  CAS  Google Scholar 

  30. Dhakal LP, Sen A, Stanko CM, et al. Early absent pupillary light reflexes after cardiac arrest in patients treated with therapeutic hypothermia. Ther Hypothermia Temp Manag. 2016;6:116–21.

    Article  Google Scholar 

  31. Steen-Hansen JE, Hansen NN, Vaagenes P, Schreiner B. Pupil size and light reactivity during cardiopulmonary resuscitation: a clinical study. Crit Care Med. 1988;16:69–70.

    Article  CAS  Google Scholar 

  32. Sims JK. Pupillary diameter in irreversible coma (letter). N Engl J Med. 1971;285:57.

    CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We thank the nurses in the Coronary Intensive Care Unit for the excellent assessments and care they provide during TTM for our patients, Katherine Cope and the Neuroscience Institute for equipment and research support, and MMCRI for grant support.

Funding

Funded by the Maine Medical Center Research Institute Summer Grant.

Author information

Authors and Affiliations

  1. Department of Critical Care Services, Maine Medical Center, 22 Bramhall Street, Portland, ME, 04102, USA

    Richard R. Riker, Teresa May, Christine Lord, Ashley Eldridge & David B. Seder

  2. Maine Medical Center Research Institute, Scarborough, ME, USA

    Mary E. Sawyer

  3. Tufts University School of Medicine, Boston, MA, USA

    Victoria G. Fischman

Authors
  1. Richard R. Riker
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mary E. Sawyer
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Victoria G. Fischman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Teresa May
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Christine Lord
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ashley Eldridge
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. David B. Seder
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors made substantial contributions to conception, design, acquisition of data, or analysis and interpretation of data. In addition, all authors assisted in the drafting or revising of the article and approved the version to be published.

Corresponding author

Correspondence to Richard R. Riker.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval/Informed consent

This study was approved by the Institutional Review Board with waiver of informed consent.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PPTX 50 kb)

Supplementary material 2 (DOCX 14 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Riker, R.R., Sawyer, M.E., Fischman, V.G. et al. Neurological Pupil Index and Pupillary Light Reflex by Pupillometry Predict Outcome Early After Cardiac Arrest. Neurocrit Care 32, 152–161 (2020). https://doi.org/10.1007/s12028-019-00717-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-019-00717-4

Keywords

Search

Navigation