Prevalence of Retinal Haemorrhages in Critically Ill Children

Journal Club Tuesday 26th June 2012

Louise Ramsden

Aim

• To determine the prevalence of retinal haemorrhage when excluding those caused by NAI

Objectives

• Search for literature relevant to question• Select a paper to discuss• Determine the validity and reliability of the paper• Assess whether this may alter local clinical practice

Why have I selected this topic?

• Literature looking at RH in abusive head trauma• Limited regarding general population

• Children with critical illness more likely to have the RFs that may be assoc with RH

The Clinical Question

Population Children without abusive head trauma

Intervention Admitted to PICU

Comparison Children with abusive head trauma

Outcome Prevalence of retinal haemorrhage

In critically ill children without abusive head trauma what is the prevalence of retinal haemorrhage and what are the associated factors?

Prevalence of Retinal Haemorrhages in Critically Ill Children

Agrawal S., Peters M.J., Adams G.G.W., Pierce C.M.

Pediatrics 2012; 129(6): e1388 – e1395

Methods

All emergency PICU admissions Excluded elective admissions,< 6 weeks of age, Direct ocular

trauma, Known / suspected AHT

Note taken of admission diagnosis, haematological Ix, CPR episodes, seizures

Consent obtained

Dilated fundoscopic exam or retinal photography

ExcludedN=254(Elective admissions 245, Direct ocular trauma 9)

Total number of PICU admissions

N=1260

Less than 6 weeks oldN=650

More than or equal to 6 weeksN=610

Met inclusion criteriaN=356

Refused ConsentN=195

RecruitedN=161

ExcludedN=2

Final AnalysesN=159

Outcome measures

No universal grading system for retinal haemorrhage

Unilateral / bilateral Mild (<5) Moderate (5-20) Severe (>20) Single or multilayered

Primary; Prevalence and distribution of retinal haemorrhages in critically ill children

Secondary; Association with admission diagnosis and coagulopathy, age and gender

Are the results of the study valid?

1 Did the study address a clearly focused issue?

Yes

- Looking at prevalence of RH- Looking for associated factors

2 Did the authors use an appropriate method to answer their question?

Yes

- Assessing prevalence

3 Was the cohort recruited in an acceptable way?

Yes

All admissions consideredConsent limited number reviewed

Excluded babies <6weeks – should they have been included?

4. Was the exposure accurately measured to minimize bias?

Yes

Cases of suspected AHT reviewed by child protection team then excluded or

included

5. Was the outcome accurately measured to minimize bias?

Can’t tell

Retinal photos used where possibleSame Consultant reviewed photos

Different people did fundoscopy

?blinded to admission reason

Parents had to give consent

6 A, Have the authors identified all important confounding factors?

Yes

No control groupConsent affecting sample size

Difficult to separate RFs

B. Have they taken account of the confounding factors in the design and/or analysis?

YesHave excluded seizures from analysis

group due to multiple RFs

Have used multivariate logistic regression analysis

7. A. Was the follow up of subjects complete enough?

B. Was the follow up of subjects long enough?

Can’t tell

Can’t tell

Only looked at a snap shot?at what point during illness does RH

occur

What are the results?• RH’s in 15.1% (95% CI 9.5-21%)• - mild 10%• - mod 1.2%• - severe 3.8%

• No impact from age, gender, traumatic brain injury, non traumatic encephalopathy

• Sepsis (OR 3.2 P=0.018) and coagulopathy (OR 2.8 P=0.025) positively assosciated

• Respiratory failure (OR 0.23 P=0.018) negatively associated

• No RH seen in CPR without assoc sepsis or coagulopathy

9. How precise are the results?

Wide confidence intervals when looking at association of individual risk factors with RH(See table 5)

10. Do you believe the results? Yes

Likely that the trend is true esp for sepsis and coagulopathy but larger sample size is needed

Looked at prevalence but also tried to identify causes and confounding factors

Will the results help me locally?

11. Can the results be applied to the local population?

Only looks at critically ill children

Would a study looking at well children be more useful?

12. Do the results of this study fit with other available evidence?

Yes and no

No direct evidence regarding coagulopathyCPR, resp illness agreesSevere retinal haemorrhage rare

Summary and Conclusion

• Prevalence of RH is 15% in critically ill children• Association with coagulopathy and sepsis• Severe RH rare with other causes

• Good study to identify prevalence• Identifys some RFs but these need closer analysis