Automated quantitative pupillometry for the prognostication of coma after cardiac arrest.
BACKGROUND
Sedation and therapeutic hypothermia (TH) delay neurological responses and might reduce the accuracy of clinical examination to predict outcome after cardiac arrest (CA). We examined the accuracy of quantitative pupillary light reactivity (PLR), using an automated infrared pupillometry, to predict outcome of post-CA coma in comparison to standard PLR, EEG, and somato-sensory evoked potentials (SSEP).


METHODS
We prospectively studied over a 1-year period (June 2012-June 2013) 50 consecutive comatose CA patients treated with TH (33 °C, 24 h). Quantitative PLR (expressed as the % of pupillary response to a calibrated light stimulus) and standard PLR were measured at day 1 (TH and sedation; on average 16 h after CA) and day 2 (normothermia, off sedation: on average 46 h after CA). Neurological outcome was assessed at 90 days with Cerebral Performance Categories (CPC), dichotomized as good (CPC 1-2) versus poor (CPC 3-5). Predictive performance was analyzed using area under the ROC curves (AUC).


RESULTS
Patients with good outcome [n = 23 (46 %)] had higher quantitative PLR than those with poor outcome [n = 27; 16 (range 9-23) vs. 10 (1-30) % at day 1, and 20 (13-39) vs. 11 (1-55) % at day 2, both p < 0.001]. Best cut-off for outcome prediction of quantitative PLR was <13 %. The AUC to predict poor outcome was higher for quantitative than for standard PLR at both time points (day 1, 0.79 vs. 0.56, p = 0.005; day 2, 0.81 vs. 0.64, p = 0.006). Prognostic accuracy of quantitative PLR was comparable to that of EEG and SSEP (0.81 vs. 0.80 and 0.73, respectively, both p > 0.20).


CONCLUSIONS
Quantitative PLR is more accurate than standard PLR in predicting outcome of post-anoxic coma, irrespective of temperature and sedation, and has comparable prognostic accuracy than EEG and SSEP.
Neuroscience Critical Care Research Group, Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University Hospital and Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
Tamarah
T
Suys
Pierre
P
Bouzat
Pedro
P
Marques-Vidal
Nathalie
N
Sala
Jean-François
JF
Payen
Andrea O
AO
Rossetti
Mauro
M
Oddo
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003128:Coma / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D005260:Female; D006323:Heart Arrest / Q000150:complications*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007259:Infrared Rays; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012025:Reflex, Pupillary / Q000502:physiology*
D006993:Hypnotics and Sedatives