Kardiyopulmoner resüsitasyon yapılan hastalarda geliş pupil çapı boyutu ve pupil ışık refleksi varlığı ile spontan dolaşımın 
geri dönüşü arasındaki ilişkinin araştırılması
The evaluation of relationship between size of pupil diameter on admission and presence of pupillary light reflex and return of spontenous circulation in patients underwent cardiopulmonary resuscitation
Yazar: MİNE KAYACI YILDIZ
Danışman: DOÇ. DR. SERKAN EMRE EROĞLU
Sağlık Bilimleri Üniversitesi / İstanbul Ümraniye Eğitim ve Araştırma Hastanesi / Acil Tıp Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2017
Konu: İlk ve Acil Yardım = Emergency and First Aid
Dizin: Acil servis-hastane = Emergency service-hospital ; Kalp durması = Heart arrest ; Kardiyopulmoner reanimasyon = Cardiopulmonary resuscitation ; Prognoz = Prognosis ; Prospektif çalışmalar = Prospective studies ; Pupilla = Pupil

Özet:
Amaç: Acil servis (AS)'te kardiyopulmoner resüsitasyon (KPR) uygulanan hastaların pupil çaplarının ve pupil ışık reflekslerinin, spontan dolaşımın geri dönüşü (SDGD) ve post-kardiyak arrest bakım hastalarında iyi nörolojik sonuçlarla ilişkili olduğu bilinmektedir. Bu çalışmada; AS'de KPR yapılan hastalarda geliş pupil çapı ve pupil ışık refleksi (PIR) varlığı ile SDGD arasında bir ilişki olup olmadığının saptanması ve geliş pupil çapı ve PIR'ın resüsitasyon prognozu üzerine etkisinin değerlendirilmesi amaçlanmıştır.
Yöntem: Bu prospektif tanımlayıcı çalışmaya, AS'ye kardiyopulmoner arrest (KPA) olarak getirilen veya hastanede KPA gelişen ve KPR uygulanan tüm erişkin hastalar ve 18 yaş altı travma hastaları dahil edildi. Pupil çapı pupilometreyle, PIR ışıklı kalem yardımıyla değerlendirildi. Veriler; t testi, ki kare testi, Pearson korelasyon analizi ve tanımlayıcı istatistikler ile değerlendirildi. P değeri ≤ 0,05 anlamlı olarak kabul edildi.
Bulgular: Hastaların ortalama yaşı 59,95 ± 20,48 (%95 GA: 55.86-64.03) idi. Hastaların %63.6'sı erkek, %36.4'ü kadındı. Çalışmaya alınan 99 vakanın 30'u hastane içinden, 69'u hastane dışından getirilen vakalardı. Bu vakaların 51 (%51,5)'inde SDGD sağlandı. Bu 51 vakanın 23'ü (%45.09) hastane içinde, 28'i (%54.91) ise hastane dışında arrest olmuştu. Geliş pupil çapı >4mm olan hasta sayısı sağ göz için 60 (%60.60) , sol göz için 58 (%58.58) idi, bu hastalardaki SDGD oranları ise sırasıyla % 31.7 ve %31.03 olarak saptandı. Geliş pupil çapı ≤4mm olan hasta sayısı sağ göz için 39 (%39.40) , sol göz için 41 (%41.42) idi, bu hastalardaki SDGD oranları ise sırasıyla % 82.05 ve %80.48 olarak saptandı Pupil çapı ile cinsiyet ve geliş şekli arasında anlamlı fark gözlenmedi. Hastane içinden KPR'ye getirilen hastalarda direkt ve indirekt PIR'larının anlamlı ölçüde korunduğu ve SDGD ile anlamlı ilişki gösterdiği saptandı. Pupil çapının gelişte 4 mm'nin üzerinde olması ve direkt PIR'ın yokluğu, eksitus ile ilişkili bulundu. Pupil çapı ile SDGD süresi arasında istatistiksel olarak anlamlı pozitif ve zayıf bir ilişki bulunduğu görülmüştür. Hastane içinden KPR için getirilen ve direkt / indirekt PIR mevcut olan hastalarda anlamlı ölçüde daha kısa sürede SDGD gerçekleştiği görüldü. Geliş şekli ile birinci hafta mortalitesi arasındaki anlamlı bir ilişki olduğu tespit edildi.
Sonuç: Bu çalışmada; KPR yapılan olgularda geliş pupil çapı boyutu ve PIR yanıtı ile SDGD arasında bir ilişki olduğu saptandı. Bu bilgiler ışığında, geliş pupil çapı ve PIR varlığına göre resüsitasyon prognozu hakkında bir değerlendirilme yapılabileceği görüldü.
Anahtar kelimeler: Acil Bakım, Kardiyak arrest, Kardiyopulmoner Resüsitasyon, Prognoz, Pupil.

Abstract:
Aim: It is known that pupil diameters and pupil light reflexes of patients receiving cardiopulmonary resuscitation (CPR) in the emergency room were related with good neurological outcomes in recovery of spontaneous circulation (ROSC) and postcardiac arrest care. The aim of the present study is to determine the relationship of ROSC with baseline pupil diameter and the presence of pupillary light reflex (PLR) in patients receiving CPR in emergency room and to evaluate the effect of baseline pupil diameter and the presence of PLR on resuscitation prognosis.
Methods: All adult patients and trauma patients younger than 18 years old who were brought with cardiopulmonary arrest (CPA) to the emergency room or patients who developed CPA in the hospital were included in this prospective descriptive study. Pupillary diameter was measured with a pupillometry and penlight was used for PLR evaluation. The data were analyzed with t test, chi-square test, Pearson's correlation analysis and descriptive statistics. A P value < 0.05 was considered statistically significant.
Results: The mean age of patients was 59.95 ± 20.48 years (95% Confidence Interval: 55.86-64.03). Sixty-three point six of the patients was male and 36.4% was female. Thirty of 99 patients were in-hospital cardiac arrest and 69 of them were out-of-hospital cardiac arrest. ROSC was achieved in 51.5% (n=51) of 99 patients. Twenty-three of (45.09%) this patients were in-hospital cardiac arrest and 28 of them (54.91%) were out-of-hospital cardiac arrest. The number of the patients who had the diameter of pupil was >4mm for right eye was 39 (39.40%), and 41 (41.42%). ROSC ratios for these groups were 82.05% and 80.48%. No significant difference was found between the pupil diameter and gender and the location of the arrests. Pupil diameters did not differ for patient genders and admission status. Direct and indirect
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PLR's were significantly conserved in patients with in-hospital CPR and were significantly related with ROSC. Death was significantly associated with baseline pupil diameter larger than 4 mm and lack of direct PLR. A significant positive weak correlation between pupil diameter and duration of ROSC was found. Patients with in-hospital CPR along with the presence of direct and indirect PLR's achieved ROSC significantly earlier. A significant correlation was detected between the admission status and mortality at first week.
Conclusion: In this study; it was determined that there was a relationship between baseline pupil diameter and the precence of PLR and ROSC in cases underwent CPR. In the light of these findings, an evaluation can be made about the resuscitation prognosis according to the pupil diameter and the presence of PLR presence.
Key words:Aim: It is known that pupil diameters and pupil light reflexes of patients receiving cardiopulmonary resuscitation (CPR) in the emergency room were related with good neurological outcomes in recovery of spontaneous circulation (ROSC) and postcardiac arrest care. The aim of the present study is to determine the relationship of ROSC with baseline pupil diameter and the presence of pupillary light reflex (PLR) in patients receiving CPR in emergency room and to evaluate the effect of baseline pupil diameter and the presence of PLR on resuscitation prognosis.
Methods: All adult patients and trauma patients younger than 18 years old who were brought with cardiopulmonary arrest (CPA) to the emergency room or patients who developed CPA in the hospital were included in this prospective descriptive study. Pupillary diameter was measured with a pupillometry and penlight was used for PLR evaluation. The data were analyzed with t test, chi-square test, Pearson's correlation analysis and descriptive statistics. A P value < 0.05 was considered statistically significant.
Results: The mean age of patients was 59.95 ± 20.48 years (95% Confidence Interval: 55.86-64.03). Sixty-three point six of the patients was male and 36.4% was female. Thirty of 99 patients were in-hospital cardiac arrest and 69 of them were out-of-hospital cardiac arrest. ROSC was achieved in 51.5% (n=51) of 99 patients. Twenty-three of (45.09%) this patients were in-hospital cardiac arrest and 28 of them (54.91%) were out-of-hospital cardiac arrest. The number of the patients who had the diameter of pupil was >4mm for right eye was 39 (39.40%), and 41 (41.42%). ROSC ratios for these groups were 82.05% and 80.48%. No significant difference was found between the pupil diameter and gender and the location of the arrests. Pupil diameters did not differ for patient genders and admission status. Direct and indirect
vii
PLR's were significantly conserved in patients with in-hospital CPR and were significantly related with ROSC. Death was significantly associated with baseline pupil diameter larger than 4 mm and lack of direct PLR. A significant positive weak correlation between pupil diameter and duration of ROSC was found. Patients with in-hospital CPR along with the presence of direct and indirect PLR's achieved ROSC significantly earlier. A significant correlation was detected between the admission status and mortality at first week.
Conclusion: In this study; it was determined that there was a relationship between baseline pupil diameter and the precence of PLR and ROSC in cases underwent CPR. In the light of these findings, an evaluation can be made about the resuscitation prognosis according to the pupil diameter and the presence of PLR presence.
Key words:Emergency Care, Cardiac Arrest, Cardiopulmonary Resuscitation, Prognosis, Pupil.