Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study.

Abstract

PURPOSE:

To assess the ability of quantitative pupillometry [using the Neurological Pupil index (NPi)] to predict an unfavorable neurological outcome after cardiac arrest (CA).

METHODS:

We performed a prospective international multicenter study (10 centers) in adult comatose CA patients. Quantitative NPi and standard manual pupillary light reflex (sPLR)-blinded to clinicians and outcome assessors-were recorded in parallel from day 1 to 3 after CA. Primary study endpoint was to compare the value of NPi versus sPLR to predict 3-month Cerebral Performance Category (CPC), dichotomized as favorable (CPC 1-2: full recovery or moderate disability) versus unfavorable outcome (CPC 3-5: severe disability, vegetative state, or death).

RESULTS:

At any time between day 1 and 3, an NPi ≤ 2 (n = 456 patients) had a 51% (95% CI 49-53) negative predictive value and a 100% positive predictive value [PPV; 0% (0-2) false-positive rate], with a 100% (98-100) specificity and 32% (27-38) sensitivity for the prediction of unfavorable outcome. Compared with NPi, sPLR had significantly lower PPV and significantly lower specificity (p  < 0.001 at day 1 and 2; p  = 0.06 at day 3). The combination of NPi ≤ 2 with bilaterally absent somatosensory evoked potentials (SSEP; n = 188 patients) provided higher sensitivity [58% (49-67) vs. 48% (39-57) for SSEP alone], with comparable specificity [100% (94-100)].

CONCLUSIONS:

Quantitative NPi had excellent ability to predict an unfavorable outcome from day 1 after CA, with no false positives, and significantly higher specificity than standard manual pupillary examination. The addition of NPi to SSEP increased sensitivity of outcome prediction, while maintaining 100% specificity.

• Authors: Mauro Oddo, Claudio Sandroni, Giuseppe Citerio, John-Paul Miroz, Janneke Horn, Malin Rundgren, Alain Cariou, Jean-François Payen, Christian Storm, Pascal Stammet, Fabio Silvio Taccone
• Journal: Intensive care medicine (Intensive Care Med) Vol. 44 Issue 12 Pg. 2102-2111 (Dec 2018) ISSN: 1432-1238 [Electronic] United States
• PMID: 30478620 (Publication Type: Comparative Study, Journal Article, Multicenter Study, Observational Study)

Topics

• Aged
• Coma (diagnosis, etiology, mortality)
• Critical Care
• Double-Blind Method
• Evoked Potentials, Somatosensory
• Female
• Glasgow Coma Scale
• Heart Arrest (complications, diagnosis, mortality)
• Humans
• Male
• Middle Aged
• Outcome Assessment, Health Care
• Prognosis
• Prospective Studies
• Reflex, Pupillary
• Sensitivity and Specificity