• John-Paul Miroz, Nawfel Ben-Hamouda, Adriano Bernini, Federico Romagnosi, Filippo Bongiovanni, Aurélien Roumy, Matthias Kirsch, Lucas Liaudet, Philippe Eckert, and Mauro Oddo.
• Department of Adult Intensive Care Medicine, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland; Neuroscience Critical Care Research Group, Lausanne University Hospital (CHUV) and the University of Lausanne, Lausanne, Switzerland.
• Chest. 2020 May 1; 157 (5): 1167-1174.

BackgroundVenoarterial 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.MethodsAn 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.ResultsOne 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).ConclusionsQuantitative 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.Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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