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
Total number of PICU admissions
N=1260
Less than 6 weeks old
N=650
Excluded
N=254
(Elective admissions 245,
Direct ocular trauma 9)
More than or equal to 6 weeks
N=610
Met inclusion criteria
N=356
Refused Consent
N=195
Recruited
N=161
Excluded
N=2
Final Analyses
N=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?
3 Was the cohort recruited in an
acceptable way?
Yes
- Assessing prevalence
Yes
All admissions considered
Consent 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 possible
Same 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 group
Consent affecting sample size
Difficult to separate RFs
B. Have they taken account of the
confounding factors in the design
and/or analysis?
Yes
Have 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?
Can’t tell
B. Was the follow up of subjects
long enough?
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 Only looks at critically ill children
local population?
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
coagulopathy
CPR, resp illness agrees
Severe 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