Abstract
BackgroundPatients who develop hospital-onset unresponsiveness should be promptly managed in order to avoid clinical deterioration. Pupillary examination through pupillary light reflex is the gold standard method in the initial evaluation of unresponsive patients. However, the current method of shining light 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 patients who developed hospital-onset unresponsiveness after admission for non-neurological reasons.MethodsThis was a registry-based observational study on patients who activated the neurological rapid response team at Asan Medical Center (Seoul, Korea). Hospital-onset unresponsiveness was defined as a newly developed unresponsive state as assessed by the ACDU (Alert, Confused, Drowsy, and Unresponsive) scale during the hospital stay. 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 unresponsiveness, 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 unresponsiveness.
Highlights
Patients who develop hospital-onset unresponsiveness should be promptly managed in order to avoid clinical deterioration
We included 404 (28%) patients who were in an unresponsive state as assessed by the ACDU scale at the time of on-call consultations to the Neurological Alert Team (NAT); and excluded 190 patients who either did not have quantitative pupillometry (QP) measurements due to NAT activation during after-hours (n = 129), showed unresponsiveness following cardiac arrest (n = 46), or had incomplete demographic data (n = 15)
Neurological outcomes were dichotomized into good outcome and poor outcome Percentage of change (CH) percentage of change (CH = 100 × [maximum pupil diameter (Max) – minimum pupil diameter (Min)]/Max), Confidence interval (CI) confidence interval, Constriction velocity (CV) constriction velocity, Dilation velocity (DV) dilation velocity, Latency of constriction (Lat) latency of constriction, Max maximal pupillary diameter, Min minimal pupillary diameter, mRS modified Rankin Scale, NAT Neurological Alert Team, NPi Neurological Pupil index, OR odds ratio neurological outcomes at 3 months was 3.0, with sensitivity of 33%, specificity of 82%, positive predictive value of 85%, and negative predictive value of 28%
Summary
Patients who develop hospital-onset unresponsiveness should be promptly managed in order to avoid clinical deterioration. 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 patients who developed hospital-onset unresponsiveness after admission for non-neurological reasons. Evaluation of the pupillary light reflexes (PLR) is conventionally performed by shining light into the patient’s eye and subjectively described by examiners. QP is able to detect subtle early changes in the size and light reflexes of pupils [6] This bedside tool is becoming popular in the routine evaluation of unresponsive patients who are admitted to intensive care units and require serial measurements of pupils, especially for those with brain herniation syndrome (BHS) [7,8,9,10]. The clinical implication of the findings of sluggish pupils remains largely uninvestigated in unresponsive patients, fixed dilated pupils inarguably suggest urgent situations and grave prognosis [3]
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