1. Prevalence of Retinal Haemorrhages in Critically Ill Children Journal Club Tuesday 26 th June 2012 Louise Ramsden

2. Aim To determine the prevalence of retinal haemorrhage when excluding those caused by NAI

3. 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

4. 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

5. The Clinical Question PopulationChildren without abusive head trauma InterventionAdmitted to PICU ComparisonChildren with abusive head trauma OutcomePrevalence of retinal haemorrhage In critically ill children without abusive head trauma what is the prevalence of retinal haemorrhage and what are the associated factors?

6. 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

7. 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

8. Excluded N=254 (Elective admissions 245, Direct ocular trauma 9) Total number of PICU admissions N=1260 Less than 6 weeks old N=650 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

9. 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

10. 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 considered Consent limited number reviewed Excluded babies <6weeks – should they have been included?

11. 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

12. 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

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

14. 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

15. 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

16. 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 coagulopathy CPR, resp illness agrees Severe retinal haemorrhage rare

17. 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