ABSTRACT
Objectives: Vasopressors are a cornerstone in the management of sepsis, marked by distributive shock often unresponsive to fluid resuscitation. Prior research and clinician surveys have suggested that earlier usage of vasopressors corresponds to improved outcomes. Methods: A retrospective cohort was constructed using patient data contained within the Medical Information Mart for Intensive Care-IV database. Analytic cohort included a total of 2079 patients meeting sepsis-3 criteria with a ≥2-point rise in Sequential Organ Failure Assessment score and administered norepinephrine (NE) as first-line vasopressor within 24 hours of admission to the intensive care unit (ICU). Patients receiving other vasopressors or missing documented fluid resuscitation information were excluded. Primary end points included mortality, use of invasive mechanical ventilation and length of stay which were analyzed in a multivariate logistic regression model for the primary effect of time from ICU admission to NE administration using covariates. Results: Time to NE use was defined as either early, using <6 hours from time of ICU admission or late using >6 hours to ≤24 hours. Patients who received early NE had significantly lower adjusted odds of mortality (0.75, 95% CI 0.57 to 0.97, p=0.026), higher adjusted odds of invasive mechanical ventilation (1.48, 95% CI 1.01 to 2.16, p=0.045), no significant difference in hospital length of stay (difference in days 0.6 (95% CI -3.24 to 2.04)) and lower ICU length of stay (difference in days -0.9 (95% CI -1.74 to -0.01)), as compared with the late NE group. Conclusion: Among patients admitted to the ICU for sepsis, early use of NE was associated with significantly lower odds of mortality but higher odds of mechanical ventilation, and no significant difference in length of hospital stay but less time in the ICU. Furthermore, the volume of fluids received prior to NE use may have a significant impact on optimal NE timing. Level of evidence: Level IV-therapeutic care/management.
ABSTRACT
Impairments in visuomotor integration (VMI) may contribute to anomalous development of motor, as well as social-communicative, skills in children with autism spectrum disorder (ASD). However, it is relatively unknown whether VMI impairments are specific to children with ASD versus children with other neurodevelopmental disorders. As such, this study addressed the hypothesis that children with ASD, but not those in other clinical control groups, would show greater deficits in high-VMI dynamic grip-force tracking versus low-VMI static presentation. Seventy-nine children, aged 7-17 years, participated: 22 children with ASD, 17 children with fetal alcohol spectrum disorder (FASD), 18 children with Attention-Deficit Hyperactivity Disorder (ADHD), and 22 typically developing (TD) children. Two grip-force tracking conditions were examined: (1) a low-VMI condition (static visual target) and (2) a high-VMI condition (dynamic visual target). Low-frequency force oscillations <0.5 Hz during the visuomotor task were also examined. Two-way ANCOVAs were used to examine group x VMI and group x frequency effects (α = 0.05). Children with ASD showed a difficulty, above that seen in the ADHD/FASD groups, tracking dynamic, but not static, visual stimuli as compared to TD children. Low-frequency force oscillations <0.25 Hz were also significantly greater in the ASD versus the TD group. This study is the first to report VMI deficits during dynamic versus static grip-force tracking and increased proportion of force oscillations <0.25 Hz during visuomotor tracking in the ASD versus TD group. Dynamic VMI impairments may be a core psychophysiologic feature that could contribute to impaired development of motor and social-communicative skills in ASD. LAY SUMMARY: Children with autism spectrum disorder (ASD) show difficulties using dynamic visual stimuli to guide their own movements compared to their typically developing (TD) peers. It is unknown whether children without a diagnosis of ASD, but with other neurological disorders, show similar difficulties processing dynamic visual stimuli. In this study, we showed that children with ASD show a difficulty using dynamic, but not static, visual stimuli to guide movement that may explain atypical development of motor and social skills.
