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Modi P, Bhoi S, Aggarwal P, Murmu LR, Sinha TP, Ekka M, Kumar A, Jamshed N. The changing paradigm from subjectivity to objectivity in pupillary assessment during neurological examination. Am J Emerg Med 2019; 37:1594-1595. [PMID: 30712949 DOI: 10.1016/j.ajem.2019.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/20/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- Priyanka Modi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, JPN Apex Trauma centre, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - L R Murmu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Tej Prakash Sinha
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Meera Ekka
- Department of Emergency Medicine, AIIMS, New Delhi, India
| | - Akshay Kumar
- Department of Emergency Medicine, AIIMS, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, AIIMS, New Delhi, India
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Couret D, Boumaza D, Grisotto C, Triglia T, Pellegrini L, Ocquidant P, Bruder NJ, Velly LJ. Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study. Crit Care 2016; 20:99. [PMID: 27072310 PMCID: PMC4828754 DOI: 10.1186/s13054-016-1239-z] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/17/2016] [Indexed: 11/10/2022]
Abstract
Background In critical care units, pupil examination is an important clinical parameter for patient monitoring. Current practice is to use a penlight to observe the pupillary light reflex. The result seems to be a subjective measurement, with low precision and reproducibility. Several quantitative pupillometer devices are now available, although their use is primarily restricted to the research setting. To assess whether adoption of these technologies would benefit the clinic, we compared automated quantitative pupillometry with the standard clinical pupillary examination currently used for brain-injured patients. Methods In order to determine inter-observer agreement of the device, we performed repetitive measurements in 200 healthy volunteers ranging in age from 21 to 58 years, providing a total of 400 paired (alternative right eye, left eye) measurements under a wide variety of ambient light condition with NeuroLight Algiscan pupillometer. During another period, we conducted a prospective, observational, double-blinded study in two neurocritical care units. Patients admitted to these units after an acute brain injury were included. Initially, nursing staff measured pupil size, anisocoria and pupillary light reflex. A blinded physician subsequently performed measurement using an automated pupillometer. Results In 200 healthy volunteers, intra-class correlation coefficient for maximum resting pupil size was 0.95 (IC: 0.93-0.97) and for minimum pupil size after light stimulation 0.87 (0.83–0.89). We found only 3-pupil asymmetry (≥1 mm) in these volunteers (1.5 % of the population) with a clear pupil asymmetry during clinical inspection. The mean pupil light reactivity was 40 ± 7 %. In 59 patients, 406 pupillary measurements were prospectively performed. Concordance between measurements for pupil size collected using the pupillometer, versus subjective assessment, was poor (Spearmen's rho = 0.75, IC: 0.70-0.79; P < 0.001). Nursing staff failed to diagnose half of the cases (15/30) of anisocoria detected using the pupillometer device. A global rate of discordance of 18 % (72/406) was found between the two techniques when assessing the pupillary light reflex. For measurements with small pupils (diameters <2 mm) the error rate was 39 % (24/61). Conclusion Standard practice in pupillary monitoring yields inaccurate data. Automated quantitative pupillometry is a more reliable method with which to collect pupillary measurements at the bedside. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1239-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Couret
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion University, BP 350, Saint Pierre, 97448, la Réunion, France.,Inserm, UMR 1188 Diabète athérothrombose Thérapies Réunion Océan Indien (DéTROI), plateforme CYROI, 2 rue Maxime Rivière, Sainte Clotilde, 97490, la Réunion, France
| | - Delphine Boumaza
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Coline Grisotto
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion University, BP 350, Saint Pierre, 97448, la Réunion, France
| | - Thibaut Triglia
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Lionel Pellegrini
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Philippe Ocquidant
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion University, BP 350, Saint Pierre, 97448, la Réunion, France
| | - Nicolas J Bruder
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France
| | - Lionel J Velly
- Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, 264 rue St Pierre, Marseille, 13005, Bouches du rhone, France.
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