Abstract
Purpose
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.
Methods
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.
Results
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.
Conclusion
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
UMIN000023729
Registry URL
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References
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.
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.
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.
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.
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.
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.
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.
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.
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.
Loewenfeld IE, Lowenstein O. The Pupil: Anatomy, Physiology, and Clinical Applications. Oxford: Butterworth Heinemann; 1999.
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.
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.
Borthne A, Davanger M. Mydriatics and age. Acta Ophthalmol. 1971;49:380–7.
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.
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.
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.
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.
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. https://doi.org/10.1097/ANA.0000000000000553.
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.
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.
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.
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.
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.
Lavie P. Ultradian rhythms in alertness—a pupillometric study. Biol Psychol. 1979;9:49–62.
Daguet I, Bouhassira D, Gronfier C. Baseline pupil diameter is not a reliable biomarker of subjective sleepiness. Front Neurol. 2019;10:108.
Loewenfeld IE. Pupillary changes related to age. Baltimore: Williams and Wilkins; 1979.
Iimura O. Insulin resistance and hypertension in Japanese. Hypertens Res. 1996;19(Suppl 1):S1–8.
Henry P, Thomas F, Benetos A, Guize L. Impaired fasting glucose, blood pressure and cardiovascular disease mortality. Hypertension. 2002;40:458–63.
Acknowledgements
We thank Angela Morben, DVM, ELS, from Edanz Group (www.edanzediting.com/ac), for editing a draft of this manuscript.
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Miyazaki, R., Sumie, M., Kandabashi, T. et al. Resting pupil size is a predictor of hypotension after induction of general anesthesia. J Anesth 33, 594–599 (2019). https://doi.org/10.1007/s00540-019-02672-y
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DOI: https://doi.org/10.1007/s00540-019-02672-y