Pupillary reflex measurement predicts insufficient analgesia before endotracheal suctioning in critically ill patients

Jerome Paulus, Antoine Roquilly, Hélène Beloeil, Julien Théraud, Karim Asehnoune, Corinne Lejus, Jerome Paulus, Antoine Roquilly, Hélène Beloeil, Julien Théraud, Karim Asehnoune, Corinne Lejus

Abstract

Introduction: This study aimed to evaluate the pupillary dilatation reflex (PDR) during a tetanic stimulation to predict insufficient analgesia before nociceptive stimulation in the intensive care unit (ICU).

Methods: In this prospective non-interventional study in a surgical ICU of a university hospital, PDR was assessed during tetanic stimulation (of 10, 20 or 40 mA) immediately before 40 endotracheal suctionings in 34 deeply sedated patients. An insufficient analgesia during endotracheal suction was defined by an increase of ≥1 point on the Behavioral Pain Scale (BPS).

Results: A total of 27 (68%) patients had insufficient analgesia. PDR with 10 mA, 20 mA and 40 mA stimulation was higher in patients with insufficient analgesia (P <0.01). The threshold values of the pupil diameter variation during a 10, 20 and 40 mA tetanic stimulation to predict insufficient analgesia during an endotracheal suctioning were 1, 5 and 13% respectively. The areas (95% confidence interval) under the receiver operating curve were 0.70 (0.54 to 0.85), 0.78 (0.61 to 0.91) and 0.85 (0.721 to 0.954) with 10, 20 and 40 mA tetanic stimulations respectively. A sensitivity analysis using the Richmond Agitation Sedation Scale (RASS) confirmed the results. The 40 mA stimulation was poorly tolerated.

Conclusions: In deeply sedated mechanically ventilated patients, a pupil diameter variation ≥5% during a 20 mA tetanic stimulation was highly predictable of insufficient analgesia during endotracheal suction. A 40 mA tetanic stimulation is painful and should not be used.

Figures

Figure 1
Figure 1
Study design. BPS, Behavioral Pain Scale; PDV, pupil diameter variation; RASS, Richmond Agitation Sedation Scale.
Figure 2
Figure 2
Flow diagram of included patients.
Figure 3
Figure 3
Comparison of the pupil diameter variation assessed after a 10, 20 or 40 mA tetanic stimulation during 40 measurements in 34 critically ill patients with adequate or insufficient analgesia. Insufficient analgesia was defined by an increase ≥1 on the Behavioral Pain Scale (A) or on the Richmond Agitation Sedation Scale (B).
Figure 4
Figure 4
Receiver operating curves for the prediction of an insufficient analgesia level before endotracheal suction by the measurement of the pupil diameter variations during 40 measurements in 34 critically ill patients after a 10, 20 or 40 mA tetanic stimulation. Insufficient analgesia was defined by an increase ≥1 on the Behavioral Pain Scale (A) or in the Richmond Agitation Sedation Scale (B).
Figure 5
Figure 5
Cardiac rate (A), respiratory rate (B), mean arterial pressure (C), number of patients with insufficient analgesia (D, E) after 10, 20 or 40 mA tetanic stimulation in 34 critically ill patients. Insufficient analgesia was defined by an increase ≥1 point on the Behavioral Pain Scale (D) or on the Richmond Agitation Sedation Scale (E).

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