Chan Wang Pong, Prescott Brenton R, Barra Megan E, Chung David Y, Kim Ivy S, Saglam Hanife, Hutch Meghan R, Shin Min, Zafar Sahar F, Benjamin Emelia J, Smirnakis Stelios M, Dupuis Josée, Greer David M, Ong Charlene J
Department of Neurology, Boston University School of Medicine, Boston, MA.
Department of Neurology, Boston Medical Center, Boston, MA.
Crit Care Explor. 2022 May 13;4(5):e0691. doi: 10.1097/CCE.0000000000000691. eCollection 2022 May.
In critically ill patients with neurologic disease, pupil examination abnormalities can signify evolving intracranial pathology. Analgesic and sedative medications (analgosedatives) target pupillary pathways, but it remains unknown how analgosedatives alter pupil findings in the clinical care setting. We assessed dexmedetomidine and other analgosedative associations with pupil reactivity and size in a heterogeneous cohort of critically ill patients with acute intracranial pathology.
Retrospective cohort study.
Two neurologic ICUs between 2016 and 2018.
Critically ill adult patients with pupil measurements within 60 minutes of analgosedative administration. Patients with a history of intrinsic retinal pathology, extracranial injury, inaccessible brain imaging, or no Glasgow Coma Scale (GCS) data were excluded.
None.
We used mixed-effects linear regression accounting for intrapatient correlations and adjusting for sex, age, GCS score, radiographic mass effect, medication confounders, and ambient light. We tested the association between an initiation or increased IV infusion of dexmedetomidine and pupil reactivity (Neurologic Pupil Index [NPi]) and resting pupil size (mm) obtained using NeurOptics NPi-200 (NeurOptics, Irvine, CA) pupillometer. Of our 221 patients with 9,897 pupil observations (median age, 60 [interquartile range, 50-68]; 59% male), 37 patients (166 pupil observations) were exposed to dexmedetomidine. Dexmedetomidine was associated with higher average NPi (β = 0.18 per 1 unit increase in rank-normalized NPi ± 0.04; < 0.001) and smaller pupil size (β = -0.25 ± 0.05; < 0.001). Exploratory analyses revealed that acetaminophen was associated with higher average NPi (β = 0.04 ± 0.02; = 0.02) and that most IV infusion analgosedatives including propofol, fentanyl, and midazolam were associated with smaller pupil size.
Dexmedetomidine is associated with higher pupil reactivity (high NPi) and smaller pupil size in a cohort of critically ill patients with neurologic injury. Familiarity with expected pupil changes following analgosedative administration is important for accurate interpretation of pupil examination findings, facilitating optimal management of patients with acute intracranial pathology.
在患有神经系统疾病的重症患者中，瞳孔检查异常可能预示着颅内病变的进展。镇痛和镇静药物（镇痛镇静剂）作用于瞳孔传导通路，但在临床护理环境中，这些药物如何改变瞳孔表现仍不清楚。我们评估了右美托咪定及其他镇痛镇静剂与患有急性颅内病变的重症患者瞳孔反应性和大小之间的关系，该队列患者情况各异。
回顾性队列研究。
2016年至2018年期间的两个神经重症监护病房。
在给予镇痛镇静剂后60分钟内进行瞳孔测量的成年重症患者。排除有视网膜内在病变、颅外损伤、无法进行脑部成像或没有格拉斯哥昏迷量表（GCS）数据的患者。
无。
我们使用了混合效应线性回归，考虑患者内部相关性，并对性别、年龄、GCS评分、影像学占位效应、药物混杂因素和环境光进行调整。我们测试了右美托咪定静脉输注起始或增加与瞳孔反应性（神经瞳孔指数[NPi]）以及使用NeurOptics NPi - 200（NeurOptics，尔湾，加利福尼亚州）瞳孔计获得的静息瞳孔大小（毫米）之间的关联。在我们221例患者的9897次瞳孔观察中（中位年龄60岁[四分位间距，50 - 68岁]；59%为男性），37例患者（166次瞳孔观察）使用了右美托咪定。右美托咪定与较高的平均NPi相关（等级标准化NPi每增加1个单位，β = 0.18 ± 0.04；P < 0.001）以及较小的瞳孔大小相关（β = -0.25 ± 0.05；P < 0.001）。探索性分析显示，对乙酰氨基酚与较高的平均NPi相关（β = 0.04 ± 0.02；P = 0.02），并且大多数静脉输注的镇痛镇静剂，包括丙泊酚、芬太尼和咪达唑仑，与较小的瞳孔大小相关。
在患有神经损伤的重症患者队列中，右美托咪定与较高的瞳孔反应性（高NPi）和较小的瞳孔大小相关。熟悉镇痛镇静剂给药后预期的瞳孔变化对于准确解读瞳孔检查结果很重要，有助于对急性颅内病变患者进行最佳管理。
