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Original Research

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Neurological pupil index during cardiopulmonary resuscitation is associated with admission to ICU in non-traumatic out-of-hospital cardiac arrest patients

  • Dong Won Kim1
  • You Hwan Jo2,3
  • Seung Min Park2,3
  • Dong Keon Lee2,3,*,†,
  • Dong-Hyun Jang4,*,†,

1Department of Emergency Medicine, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, 24253 Chuncheon, Republic of Korea

2Department of Emergency Medicine, Seoul National University Bundang Hospital, 13620 Seongnam, Republic of Korea

3Department of Emergency Medicine, Seoul National University College of Medicine, 03080 Seoul, Republic of Korea

4Department of Emergency Medicine, Korea University Anam Hospital, 02841 Seoul, Republic of Korea

DOI: 10.22514/sv.2022.038

Submitted: 16 December 2021 Accepted: 10 February 2022

Online publish date: 12 May 2022

*Corresponding Author(s): Dong Keon Lee E-mail:
*Corresponding Author(s): Dong-Hyun Jang E-mail:

† These authors contributed equally.


Pupillary light reflex (PLR) is a simple method to assess brainstem function and can be measured objectively and accurately using pupillometry. We sought to investigate the relationship between PLR measured with pupillometry during cardiopulmonary resuscitation (CPR) and early prognosis of out-of-hospital cardiac arrest (OHCA) patients. This study was a single-centre prospective observational study. All OHCA patients who received CPR in the emergency department (ED) from August 2019 to January 2021 were registered, and adult patients whose neurological pupil index (NPi) was measured with an automated pupillometer during CPR in the ED were included. The primary outcome was admission to the intensive care unit (ICU). A total of 109 patients were included, and the mean of the NPi measurements of all the patients was 0.1 ± 0.7. The mean of the NPi was higher in the patients admitted to the ICU than in those who died in the ED, 0.5 ± 1.2 vs. 0.0 ± 0.1 (p = 0.031). Receiver operating characteristic analysis was performed to determine the cut-off value of the NPi, and the optimal cut-off value for ICU admission was 2.0 with sensitivity and specificity 0.769 and 0.652, respectively. Patients with NPi >2.0 showed higher rates of admission to ICU, ICU survival, and good neurologic outcomes at hospital discharge and at 3 months following cardiac arrest, than the patients with NPi ≤2.0. Firth’s bias-reduced penalised-likelihood multivariable logistic regression analysis showed that the odds ratio of the group with NPi >2.0 was 14.37 (95% confidence interval, 1.80–179.12), which was an independent variable associated with admission to ICU. NPi of higher than 2.0 is one of the indicators associated with an early favourable outcome of OHCA patients.


Pupillary reflex; Out-of-hospital cardiac arrest; Prognosis

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Dong Won Kim,You Hwan Jo,Seung Min Park,Dong Keon Lee,Dong-Hyun Jang. Neurological pupil index during cardiopulmonary resuscitation is associated with admission to ICU in non-traumatic out-of-hospital cardiac arrest patients. Signa Vitae. 2022.doi:10.22514/sv.2022.038.


[1] Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Part 3: adult basic and advanced life support: 2020 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; 142: S366–S468.

[2] Takegawa R, Shiozaki T, Ogawa Y, Hirose T, Mori N, Ohnishi M, et al. Usefulness of cerebral rSO2 monitoring during CPR to predict the probability of return of spontaneous circulation. Resuscitation. 2019; 139: 201–207.

[3] Drennan IR, Case E, Verbeek PR, Reynolds JC, Goldberger ZD, Jasti J, et al. A comparison of the universal TOR guideline to the absence of prehospital ROSC and duration of resuscitation in predicting futility from out-of-hospital cardiac arrest. Resuscitation. 2017; 111: 96–102.

[4] Couret D, Boumaza D, Grisotto C, Triglia T, Pellegrini L, Ocquidant P, et al. Reliability of standard pupillometry practice in neurocritical care: an observational, double-blinded study. Critical Care. 2016; 20: 99.

[5] Chen JW, Gombart ZJ, Rogers S, Gardiner SK, Cecil S, Bullock RM. Pupillary reactivity as an early indicator of increased intracranial pressure: the introduction of the neurological pupil index. Surgical Neurology International. 2011; 2: 82.

[6] Lee HJ, Shin J, Hong KJ, Jung JH, Lee SJ, Jung E, et al. A feasibility study for the continuous measurement of pupillary response using the pupillography during CPR in out-of-hospital cardiac arrest patients. Resuscitation. 2019; 135: 80–87.

[7] Behrends M, Niemann CU, Larson MD. Infrared pupillometry to detect the light reflex during cardiopulmonary resuscitation: a case series. Resuscitation. 2012; 83: 1223–1228.

[8] Tamura T, Namiki J, Sugawara Y, Sekine K, Yo K, Kanaya T, et al. Early outcome prediction with quantitative pupillary response parameters after out-of-hospital cardiac arrest: a multicenter prospective observational study. PLoS One. 2020;15: e0228224.

[9] Riker RR, Sawyer ME, Fischman VG, May T, Lord C, Eldridge A, et al. Neurological pupil index and pupillary light reflex by pupillometry predict outcome early after cardiac arrest. Neurocritical Care. 2020; 32: 152–161.

[10] Obling L, Hassager C, Illum C, Grand J, Wiberg S, Lindholm MG, et al. Prognostic value of automated pupillometry: an unselected cohort from a cardiac intensive care unit. European Heart Journal-Acute Cardiovascular Care. 2020; 9: 779–787.

[11] Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, et al. Part 7: adult advanced cardiovascular life support: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015; 132: S444–S464.

[12] Morrison LJ, Kierzek G, Diekema DS, Sayre MR, Silvers SM, Idris AH, et al. Part 3: ethics: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010; 122: S665–S675.

[13] Larson MD, Behrends M. Portable infrared pupillometry: a review. Anesthesia & Analgesia. 2015; 120: 1242–1253.

[14] Lussier BL, Stutzman SE, Atem F, Venkatachalam AM, Perera AC, Barnes A, et al. Distributions and reference ranges for automated pupil-lometer values in neurocritical care patients. Journal of Neuroscience Nursing. 2019; 51: 335–340.

[15] Perkins GD, Jacobs IG, Nadkarni VM, Berg RA, Bhanji F, Biarent D, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein resuscitation registry templates for out-of-hospital cardiac arrest: a statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American heart association, European resuscitation council, Australian and New Zealand council on resuscitation, heart and stroke foundation of Canada, interAmerican heart foundation, resuscitation council of Southern Africa, resuscitation council of Asia); and the American heart association emergency cardiovascular care committee and the council on cardiopulmonary, critical care, perioperative and resuscitation. Circulation. 2015; 132: 1286–1300.

[16] Posner JB, Saper CB, Schiff N, Plum F. Plum and posner’s diagnosis of stupor and coma. 4th edn. Oxford University Press: New York. 2008.

[17] Binnion PF, McFarland RJ. The relationship between cardiac massage and pupil size in cardiac arrest in dogs. Cardiovascular Research. 1968; 2: 247–251.

[18] Messer JV. Management of emergencies. XIV. Cardiac arrest. New England Journal of Medicine. 1966; 275: 35–39.

[19] Lewis FR, Trunkey DD. Pupillary reactivity in circulatory arrest. Surgery. 1984; 95: 380.

[20] Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S. Practice param-eter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the quality standards subcommittee of the american academy of neurology. Neurology. 2006; 67: 203–210.

[21] Zandbergen EGJ. Prediction of outcome in anoxic-ischaemic coma [PhD’s thesis]. University of Amsterdam. 2006.

[22] Du R, Meeker M, Bacchetti P, Larson MD, Holland MC, Manley GT. Evaluation of the portable infrared pupillometer. Neurosurgery. 2005; 57: 198–203.

[23] Litvan I, Saposnik G, Maurino J, Gonzalez L, Saizar R, Sica RE, et al. Pupillary diameter assessment: need for a graded scale. Neurology. 2000; 54: 530–531.

[24] Larson MD, Muhiudeen I. Pupillometric analysis of the “absent light reflex”. Archives of Neurology. 1995; 52: 369–372.

[25] Oddo M, Sandroni C, Citerio G, Miroz JP, Horn J, Rundgren M, et al. Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study. Intensive Care Medicine. 2018; 44: 2102–2111.

[26] Zhao D, Weil MH, Tang W, Klouche K, Wann SR. Pupil diameter and light reaction during cardiac arrest and resuscitation. Critical Care Medicine. 2001; 29: 825–828.

[27] Steen-Hansen JE, Hansen NN, Vaagenes P, Schreiner B. Pupil size and light reactivity during cardiopulmonary resuscitation: a clinical study. Critical Care Medicine. 1988; 16: 69–70.

[28] Achamallah N, Fried J, Love R, Matusov Y, Sharma R. Pupillary light reflex is not abolished by epinephrine and atropine given during advanced cardiac life support in patients who achieve return of spontaneous circulation. Journal of Intensive Care Medicine. 2021; 36: 459–465.

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