Depending on pupillary status, neurosurgeons triage patients into either conservative therapy or surgical evacuation of mass lesions. Pupillary information is relied on to guide decisions regarding patient triage and clinical intervention. Cranial nerve dysfunction may signal increased ICP and/or an increased risk of brain herniation. (4, 26, 34, 41, 46, 47, 50, 55, 63) Pupillary examination involves assessment of the functional status of two cranial nerves (CN) – the optic nerve (CN II) and the oculomotor nerve (CN III). Today, clinicians routinely evaluate pupils as part of the neurological exam and monitoring of all critically ill patients, including those with primary neurological injury as well as those at risk of secondary neurologic insults. (28, 34, 46) For centuries, clinicians have assessed the pupils of patients with impaired consciousness. The clinical neurological exam is an essential component in the assessment and care of patients with a wide variety of illnesses and injuries. Prognostic value after traumatic brain injury, cardiac arrest and ECMO (27, 42, 45, 57) Monitoring response to therapeutic interventions (hyperosmolar therapy) (27, 29, 49) Early indication of neurological worsening (cerebral edema, elevation in ICP, delayed cerebral ischemia, identification of herniation syndromes) (1, 5, 14, 19, 27, 29, 30, 39, 49, 51, 52) Accuracy of measurement in common critical care scenarios (sedation and pharmacologic paralysis) (23, 30, 31, 42, 45, 58) Improvement in inter-rater reliability of pupillary metrics (1, 46, 48) The following findings have been objectively demonstrated when quantitative pupillometry is utilized: On the numeric NPi ® scale, an NPi ® from 3.0 to 4.9 is considered normal, while an NPi ® less than 3.0 is considered abnormal. The Neurological Pupil index (NPi ®), calculated by the Pupillometer, reflects a comparison of all measured variables in the PLR to known normal observations. The NeurOptics NPi ®-200 Pupillometer is a handheld, automated device that provides an accurate, reliable, and objective measurement of pupillary size, symmetry, and reactivity through measurement of the entire pupillary light reflex (PLR). Manual pupillary assessment, using a flashlight or penlight, is prone to many sources of inaccuracy and is characterized by subjectivity and low interrater reliability. Pupillary changes correlate with neurological worsening and yet are often undetectable using traditional manual assessment methods. Accurate serial neurological assessment is imperative to 1) rapidly detect changes that may indicate neurologic deterioration, 2) guide patient management, 3) determine the effect of therapeutic interventions and 4) inform prognosis.Īssessment of pupil size and the pupillary light reflex is a critical component of the neurological exam for patients in various settings (26, 50, 55) such as the Emergency Department (ED), Intensive Care Unit (ICU), Operating Room (OR), Post Anesthesia Care Unit (PACU), diagnostic areas such as Interventional Radiology (IR), and Progressive Care Units (PCU). Patients with primary or secondary neurological insult are at risk for development of hydrocephalus, cerebral edema, elevated intracranial pressure (ICP), and brain herniation. As standard of care, all critically ill patients require routine neurologic examination, including pupillary assessment.
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