Validating quantitative pupillometry thresholds for neuroprognostication after out-of-hospital cardiac arrest. A predefined substudy of the Blood Pressure and Oxygenations Targets After Cardiac Arrest (BOX)-trial

• Published in: Intensive care medicine 2024-09, Vol.50 (9), p.1484-1495
• Main Authors: Nyholm, Benjamin, Grand, Johannes, Obling, Laust E. R., Hassager, Christian, Møller, Jacob Eifer, Schmidt, Henrik, Othman, Marwan H., Kondziella, Daniel, Horn, Janneke, Kjaergaard, Jesper
• Format: Article
• Language: English
• Subjects: Aged; Anesthesiology; Automation; Blood pressure; Brain injury; Cardiac arrest; Cardiopulmonary Resuscitation - methods; Coma; Coma - etiology; Coma - physiopathology; Critical Care Medicine; Emergency Medicine; Female; Head injuries; Heart; Hospitals; Humans; Hypoxia; Injury prevention; Intensive; Ischemia; Male; Medicine; Medicine & Public Health; Middle Aged; NCT; NCT03141099; Original; Out-of-Hospital Cardiac Arrest - complications; Out-of-Hospital Cardiac Arrest - physiopathology; Out-of-Hospital Cardiac Arrest - therapy; Pain Medicine; Patients; Pediatrics; Performance prediction; Phosphopyruvate hydratase; Pneumology/Respiratory System; Prognosis; Pupillometry; Reflex, Pupillary - physiology; Sensitivity; Survival; Thresholds
• ISSN: 0342-4642; 1432-1238; 1432-1238
• DOI: 10.1007/s00134-024-07574-6

Purpose Out-of-hospital cardiac arrest (OHCA) survivors face significant risks of complications and death from hypoxic–ischemic brain injury leading to withdrawal of life-sustaining treatment (WLST). Accurate multimodal neuroprognostication, including automated pupillometry, is essential to avoid inappropriate WLST. However, inconsistent study results hinder standardized threshold recommendations. We aimed to validate proposed pupillometry thresholds with no false predictions of unfavorable outcomes in comatose OHCA survivors. Methods In the multi-center BOX-trial, quantitative measurements of automated pupillometry (quantitatively assessed pupillary light reflex [qPLR] and Neurological Pupil index [NPi]) were obtained at admission (0 h) and after 24, 48, and 72 h in comatose patients resuscitated from OHCA. We aimed to validate qPLR  60 μg/L, pupillometry was evaluated for multimodal neuroprognostication in comatose patients with Glasgow Motor Score ( M ) ≤ 3 at ≥ 72 h. Results From March 2017 to December 2021, we consecutively enrolled 710 OHCA survivors (mean age: 63 ± 14 years; 82% males), and 266 (37%) patients had unfavorable neurological outcomes. An NPi ≤ 2 predicted outcome with 0% false-positive rate (FPR) at all time points (0–72 h), and qPLR