Abstract
We aimed to determine the characteristics of quantitative pupillary response parameters other than amplitude of pupillary light reflex (PLR) early after return of spontaneous circulation (ROSC) and their implications for predicting neurological outcomes early after cardiac arrest (CA). Fifty adults resuscitated after non-traumatic out-of-hospital CA from four emergency hospitals were enrolled. Pupil diameters, PLR, constriction velocity (CV), maximum CV (MCV), dilation velocity (DV), latency of constriction, and Neurological Pupil index (NPi) were quantitatively measured at 0, 6, 12, 24, 48, and 72 h post-ROSC using an automated pupillometer. Change over time of each parameter was compared between favorable (Cerebral Performance Category [CPC] 1 or 2) and unfavorable neurological outcome (CPC 3-5) groups. Prognostic values of 90-day favorable outcome by these parameters and when combined with clinical predictors (witness status, bystander cardiopulmonary resuscitation, initial shockable rhythm, implementation of target temperature management) were tested. Thirteen patients achieved favorable outcome. CV, MCV, DV (P < 0.001), and NPi (P = 0.005) were consistently greater in the favorable group than in the unfavorable outcome group. Change over time was not statistically different between the groups in all parameters. CV, MCV, DV (ρ = 0.96 to 0.97, P < 0.001, respectively), and NPi (ρ = 0.65, P < 0.001) positively correlated with PLR. The prognostic value of 0-hour CV (area under the curve, AUC [95% confidence interval]: 0.92 [0.80-1.00]), DV (0.84 [0.68-0.99]), and NPi (0.88 [0.74-1.00]) was equivalent to that of PLR (0.84 [0.69-0.98]). Prognostic values improved to AUC of 0.95-0.96 when 0-hour PLR, CV, DV, or NPi was combined with clinical predictors. The 0-hour CV, MCV, and NPi showed equivalent prognostic values to PLR alone/in combination with clinical predictors. Using PLR among several quantitative pupillary response parameters for early neurological prognostication of post-CA patients is a simple and effective strategy.
Highlights
The incidence of neurological sequelae among survivors of out-of-hospital cardiac arrest (OHCA) remains as high as 75% despite advances in post-arrest care [1]
We have reported that quantitative values of pupillary light reflex (PLR) in survivors or in patients with favorable neurological outcomes were consistently greater than values in non-survivors or in patients with unfavorable outcomes, respectively, within 72 h following the return of spontaneous circulation (ROSC) after OHCA [9]
This study is a post-hoc analysis of a multicenter, single-arm, uncontrolled, prospective, observational study that focused on quantitative PLR as a representative parameter of pupillary responses [9]
Summary
The incidence of neurological sequelae among survivors of out-of-hospital cardiac arrest (OHCA) remains as high as 75% despite advances in post-arrest care [1]. In comatose post-cardiac arrest (CA) patients, bilateral absence of pupillary reflex to light at 72 h or longer after CA strongly predicts poor neurological outcome [4]. In the last several years, quantitative assessment of pupillary light reflex (PLR) has emerged as a promising modality for predicting neurological outcomes in post-CA patients. We have reported that quantitative values of PLR in survivors or in patients with favorable neurological outcomes were consistently greater than values in non-survivors or in patients with unfavorable outcomes, respectively, within 72 h following the return of spontaneous circulation (ROSC) after OHCA [9]. Quantitative PLR strongly predicted 90-day survival and favorable neurological outcomes as early as 0 h after ROSC
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