Journal of Anesthesia

, Volume 33, Issue 5, pp 594–599 | Cite as

Resting pupil size is a predictor of hypotension after induction of general anesthesia

  • Ryohei MiyazakiEmail author
  • Makoto Sumie
  • Tadashi Kandabashi
  • Ken Yamaura
Original Article



Arterial hypotension is a major adverse effect of general anesthesia. Patients with pre-existing autonomic dysfunction are at greater risk of hypotension. This study was performed to examine whether objective measurement of the pupillary light reflex is predictive of intraoperative hypotension.


We studied 79 patients who underwent scheduled surgery under general anesthesia. Patients with severe cardiovascular disease or receiving antihypertensive agents were excluded. The light reflex was measured preoperatively using a portable infrared pupillometer, and the hemodynamic parameters were obtained from the anesthesia records. The patients were divided into two groups according to the development of hypotension: the hypotension and normotension groups. Multivariate logistic regression analysis was performed to determine the pupil parameters predictive of hypotension.


Patients in the hypotension group were older and had a greater pupil size or constriction velocity than those in the normotension group. Logistic regression analysis showed that post-induction hypotension was significantly associated with maximum pupil size or constriction velocity after adjustment for age and other clinical variables. Latency of the light reflex and the percent reduction of pupil size were not associated with hypotension. Age was a relatively strong predictor of hypotension; other confounding factors were not associated with hypotension.


Measurement of maximum pupil size is useful to identify patients at risk for intraoperative hypotension. The influence of age must be considered during measurement of the pupil response.

Clinical trial number



Pupillary light reflex Hypotension General anesthesia 



We thank Angela Morben, DVM, ELS, from Edanz Group (, for editing a draft of this manuscript.


Support was provided solely from departmental sources.

Compliance with ethical standards

Conflict of interest

The authors declare no competing interests.


  1. 1.
    van Waes JA, van Klei WA, Wijeysundera DN, van Wolfswinkel L, Lindsay TF, Beattie WS. Association between intraoperative hypotension and myocardial injury after vascular surgery. Anesthesiology. 2016;124:35–44.CrossRefGoogle Scholar
  2. 2.
    Bijker JB, Persoon S, Peelen LM, Moons KG, Kalkman CJ, Kappelle LJ, van Klei WA. Intraoperative hypotension and perioperative ischemic stroke after general surgery: a nested case–control study. Anesthesiology. 2012;116:658–64.CrossRefGoogle Scholar
  3. 3.
    Maheshwari K, Turan A, Mao G, Yang D, Niazi AK, Agarwal D, Sessler DI, Kurz A. The association of hypotension during non-cardiac surgery, before and after skin incision, with postoperative acute kidney injury: a retrospective cohort analysis. Anaesthesia. 2018;73:1223–8.CrossRefGoogle Scholar
  4. 4.
    Tassoudis V, Vretzakis G, Petsiti A, Stamatiou G, Bouzia K, Melekos M, Tzovaras G. Impact of intraoperative hypotension on hospital stay in major abdominal surgery. J Anesth. 2011;25:492–9.CrossRefGoogle Scholar
  5. 5.
    Monk TG, Bronsert MR, Henderson WG, Mangione MP, Sum-Ping ST, Bentt DR, Nguyen JD, Richman JS, Meguid RA, Hammermeister KE. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology. 2015;123:307–19.CrossRefGoogle Scholar
  6. 6.
    Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, Bodian CA. Predictors of hypotension after induction of general anesthesia. Anesth Analg. 2005;101:622–8.CrossRefGoogle Scholar
  7. 7.
    Südfeld S, Brechnitz S, Wagner JY, Reese PC, Pinnschmidt HO, Reuter DA, Saugel B. Post-induction hypotension and early intraoperative hypotension associated with general anaesthesia. Br J Anaesth. 2017;119:57–64.CrossRefGoogle Scholar
  8. 8.
    Burgos LG, Ebert TJ, Asiddao C, Turner LA, Pattison CZ, Wang-Cheng R, Kampine JP. Increased intraoperative cardiovascular morbidity in diabetics with autonomic neuropathy. Anesthesiology. 1989;70:591–7.CrossRefGoogle Scholar
  9. 9.
    Bein B, Hanss R, Scholz J, Tonner PH. Pre-operative measurement of heart rate variability and incidence of hypotension. Acta Anaesthesiol Scand. 2006;50:1170–1.CrossRefGoogle Scholar
  10. 10.
    Loewenfeld IE, Lowenstein O. The Pupil: Anatomy, Physiology, and Clinical Applications. Oxford: Butterworth Heinemann; 1999.Google Scholar
  11. 11.
    Muppidi S, Adams-Huet B, Tajzoy E, Scribner M, Blazek P, Spaeth EB, Frohman E, Davis S, Vernino S. Dynamic pupillometry as an autonomic testing tool. Clin Auton Res. 2013;23:297–303.CrossRefGoogle Scholar
  12. 12.
    Guillon M, Dumbleton K, Theodoratos P, Gobbe M, Wooley CB, Moody K. The effects of age, refractive status, and luminance on pupil size. Optom Vis Sci. 2016;93:1093–100.CrossRefGoogle Scholar
  13. 13.
    Borthne A, Davanger M. Mydriatics and age. Acta Ophthalmol. 1971;49:380–7.CrossRefGoogle Scholar
  14. 14.
    Okutucu S, Civelekler M, Aparci M, Sabanoglu C, Dikmetas O, Aksoy H, Yetis Sayin B, Oto A. Computerized dynamic pupillometry indices mirrors the heart rate variability parameters. Eur Rev Med Pharmacol Sci. 2016;20:2099–105.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Boev AN, Fountas KN, Karampelas I, Boev C, Machinis TG, Feltes C, Okosun I, Dimopoulos V, Troup C. Quantitative pupillometry: normative data in healthy pediatric volunteers. J Neurosurg. 2005;103:496–500.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Oddo M, Sandroni C, Citerio G, Miroz JP, Horn J, Rundgren M, Cariou A, Payen JF, Storm C, Stammet P, Taccone FS. Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study. Intensive Care Med. 2018;44:2102–11.CrossRefGoogle Scholar
  17. 17.
    Jahns FP, Miroz JP, Messerer M, Daniel RT, Taccone FS, Eckert P, Oddo M. Quantitative pupillometry for the monitoring of intracranial hypertension in patients with severe traumatic brain injury. Crit Care. 2019;23:155.CrossRefGoogle Scholar
  18. 18.
    Natzeder S, Mack DJ, Maissen G, Strässle C, Keller E, Muroi C. Portable infrared pupillometer in patients with subarachnoid hemorrhage: prognostic value and circadian rhythm of the Neurological Pupil Index (NPi). J Neurosurg Anesthesiol. 2018. Scholar
  19. 19.
    Rollins MD, Feiner JR, Lee JM, Shah S, Larson M. Pupillary effects of high-dose opioid quantified with infrared pupillometry. Anesthesiology. 2014;121:1037–44.CrossRefGoogle Scholar
  20. 20.
    Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49:1373–9.CrossRefGoogle Scholar
  21. 21.
    Ewing DJ, Martyn CN, Young RJ, Clarke BF. The value of cardiovascular autonomic function tests: 10 years experience in diabetes. Diabetes Care. 1985;8:491–8.CrossRefGoogle Scholar
  22. 22.
    Hermida RC, Ayala DE, Fernández JR, Mojón A, Alonso I, Calvo C. Modeling the circadian variability of ambulatorily monitored blood pressure by multiple-component analysis. Chronobiol Int. 2002;19:461–81.CrossRefGoogle Scholar
  23. 23.
    Vandewalle G, Middleton B, Rajaratnam SM, Stone BM, Thorleifsdottir B, Arendt J, Dijk DJ. Robust circadian rhythm in heart rate and its variability: influence of exogenous melatonin and photoperiod. J Sleep Res. 2007;16:148–55.CrossRefGoogle Scholar
  24. 24.
    Lavie P. Ultradian rhythms in alertness—a pupillometric study. Biol Psychol. 1979;9:49–62.CrossRefGoogle Scholar
  25. 25.
    Daguet I, Bouhassira D, Gronfier C. Baseline pupil diameter is not a reliable biomarker of subjective sleepiness. Front Neurol. 2019;10:108.CrossRefGoogle Scholar
  26. 26.
    Loewenfeld IE. Pupillary changes related to age. Baltimore: Williams and Wilkins; 1979.Google Scholar
  27. 27.
    Iimura O. Insulin resistance and hypertension in Japanese. Hypertens Res. 1996;19(Suppl 1):S1–8.CrossRefGoogle Scholar
  28. 28.
    Henry P, Thomas F, Benetos A, Guize L. Impaired fasting glucose, blood pressure and cardiovascular disease mortality. Hypertension. 2002;40:458–63.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2019

Authors and Affiliations

  1. 1.Operating RoomsKyushu University HospitalFukuokaJapan
  2. 2.Department of Anesthesiology and Critical Care MedicineKyushu University HospitalFukuokaJapan
  3. 3.Medical Information CenterKyushu University HospitalFukuokaJapan
  4. 4.Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical SciencesKyushu UniversityFukuokaJapan

Personalised recommendations