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Using Pupillary Pain Index to Assess Nociception in Sedated Critically Ill Patients

Vinclair, Marc MD*; Schilte, Clotilde MD*; Roudaud, Florian MD*; Lavolaine, Julien MD*; Francony, Gilles MD*; Bouzat, Pierre MD, PhD*,†,‡; Bosson, Jean-Luc MD, PhD§,‖; Payen, Jean-Francois MD, PhD*,†,‡

doi: 10.1213/ANE.0000000000004173
Technology, Computing, and Simulation: Original Clinical Research Report
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BACKGROUND: Pupillary reflex dilation is a reliable indicator of response to noxious stimulation. In a proof of concept study, we investigated the performance of pupillary pain index, a new score derived from pupillary reflex dilation measurements, to predict nociceptive response to endotracheal suctioning in sedated critically ill patients.

METHODS: Twenty brain-injured and 20 non–brain-injured patients were studied within 48 hours of admission (T1) in the intensive care unit and at 48–72 hours later (T2). Video-based pupillometer was used to determine pupillary reflex dilation during tetanic stimulation. The tetanic stimulation (100 Hz) was applied to the skin area innervated by the ulnar nerve and was stepwise increased from 10 to 60 mA until pupil size had increased by 13% compared to baseline. The maximum intensity value allowed the determination of a pupillary pain index score ranging from 1 (no nociception) to 9 (high nociception). The Behavioral Pain Scale response to endotracheal suctioning was measured thereafter.

RESULTS: Behavioral Pain Scale responses to endotracheal suctioning and pupillary pain index scores were positively correlated at T1 and T2 (both P < .01). After adjustments for repeated measurements and group of patients, the area under the receiver operating characteristic curve of pupillary pain index to predict Behavioral Pain Scale response to endotracheal suctioning was of 0.862 (95% CI, 0.714–0.954). In the combined set of patients, a pupillary pain index score of ≤4 could predict no nociceptive response to endotracheal suctioning with a sensitivity of 88% (95% CI, 68%–97%) and a specificity of 79% (95% CI, 66%–88%). By contrast with endotracheal suctioning, tetanic stimulation had no effect on intracranial pressure in the brain-injured group.

CONCLUSIONS: These results are a proof of concept. The nociceptive response to endotracheal suctioning could be accurately predicted using the determination of pupillary pain index score in sedated critically ill patients whether they have brain injury or not.

From the *Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France

Institut National de la Santé et de la Recherche Médicale, U1216, F-38000 Grenoble, France

Université Grenoble Alpes, Grenoble Institut des Neurosciences, F-38000 Grenoble, France

§Clinical Research Centre, Institut National de la Santé et de la Recherche Médicale 003, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France

Université Grenoble Alpes, Centre National de la Recherche Scientifique-Mathématiques et Applications, Grenoble Unité Mixte de Recherche, 5525-ThEMAS, F-38000 Grenoble, France.

Published ahead of print 15 April 2019.

Accepted for publication February 6, 2019.

Funding: This study was supported by a grant from the Fondation Apicil (Lyon, France).

The authors declare no conflicts of interest.

Trial registration: Clinicaltrials.gov identifier NCT02843893.

The sponsor had no role in the study design, data collection, data analysis, data interpretation, or writing of the report.

Reprints will not be available from the authors.

Address correspondence to Jean-Francois Payen, MD, PhD, Pôle Anesthésie Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, F-38000, Grenoble, France. Address e-mail to jfpayen@univ-grenoble-alpes.fr.

Copyright © 2019 International Anesthesia Research Society
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