1. Neurological Pupil index for Early Prognostication After Venoarterial Extracorporeal Membrane Oxygenation
- Author
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Philippe Eckert, Lucas Liaudet, Aurélien Roumy, Mauro Oddo, Adriano Bernini, Federico Romagnosi, John-Paul Miroz, Matthias Kirsch, Filippo Bongiovanni, and Nawfel Ben-Hamouda
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.medical_treatment ,Shock, Cardiogenic ,Reflex, Pupillary ,Critical Care and Intensive Care Medicine ,Sensitivity and Specificity ,Pupil ,03 medical and health sciences ,Extracorporeal Membrane Oxygenation ,0302 clinical medicine ,Refractory ,Interquartile range ,Internal medicine ,mental disorders ,medicine ,Extracorporeal membrane oxygenation ,Humans ,030212 general & internal medicine ,Coma ,Aged ,Neurologic Examination ,business.industry ,Cardiogenic shock ,Middle Aged ,Prognosis ,medicine.disease ,humanities ,Heart Arrest ,Survival Rate ,surgical procedures, operative ,030228 respiratory system ,Cohort ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,Early phase ,business ,Switzerland ,Pupillometry - Abstract
Venoarterial extracorporeal membrane oxygenation therapy (VA-ECMO) after refractory cardiogenic shock or cardiac arrest has significant morbidity and mortality. Early outcome prediction is crucial in this setting, but data on neuroprognostication are limited. We examined the prognostic value of clinical neurologic examination, using an automated device for the quantitative measurement of pupillary light reactivity.An observational cohort of sedated, mechanically ventilated VA-ECMO patients was analyzed during the early phase after ECMO insertion (first 72 h). Using the NPi-200 automated infrared pupillometer, pupillary light reactivity was assessed repeatedly (every 12 h) by calculating the Neurological Pupil index (NPi). Trends of NPi over time were correlated to 90-day mortality, and the prognostic performance of the NPi, alone and in combination with the 12-h PREDICT VA-ECMO score, was evaluated.One hundred consecutive patients were studied (51 with refractory cardiogenic shock and 49 with refractory cardiac arrest; 12-h PREDICT VA-ECMO, 40%; observed 90-day survival, 43%). Nonsurvivors (n = 57) had significantly lower NPi than did survivors at all time points (all P .01). Abnormal NPi (3, at any time from 24 to 72 h) was 100% specific for 90-day mortality, with 0% false positives. Adding the 12-h PREDICT VA-ECMO score to the NPi provided the best prognostic performance (specificity, 100% [95% CI, 92%-100%]; sensitivity, 60% [95% CI, 46%-72%]; area under the receiver operating characteristic curve, 0.82).Quantitative NPi alone had excellent ability to predict a poor outcome from day 1 after VA-ECMO insertion, with no false positives. Combining NPi and 12-h PREDICT-VA ECMO score increased the sensitivity of outcome prediction, while maintaining 100% specificity.
- Published
- 2020