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BACKGROUND: Little is known about the airway microbiome in intubated mechanically ventilated children. We sought to characterize the airway microbiome longitudinally and in association with clinical variables and possible ventilator-associated infection (VAI). METHODS: Serial tracheal aspirate samples were prospectively obtained from mechanically ventilated subjects under 3 years old from eight pediatric intensive care units in the United States from June 2017 to July 2018. Changes in the tracheal microbiome were analyzed by sequencing bacterial 16S ribosomal RNA gene relative to subject demographics, diagnoses, clinical parameters, outcomes, antibiotic treatment, and the Ventilator-Associated InfectioN (VAIN) score. RESULTS: A total of 221 samples from 58 patients were processed and 197 samples met the >1000 reads criteria (89%), with an average of 43,000 reads per sample. The median number of samples per subject was 3 (interquartile range [IQR]: 2–5), with a median VAIN score of 2 (IQR: 1–3). Proteobacteria was the highest observed phyla throughout the intubation period, followed by Firmicutes and Actinobacteria. Alpha diversity was negatively associated with days of intubation (p = .032) and VAIN score (p = .016). High VAIN scores were associated with a decrease of Mycobacterium obuense, and an increase of Streptococcus peroris, Porphyromonadaceae family (unclassified species), Veillonella atypica, and several other taxa. No specific pattern of microbiome composition related to clinically diagnosed VAIs was observed. CONCLUSIONS: Our data demonstrate decreasing alpha diversity with increasing VAIN score and days of intubation. No specific microbiome pattern was associated with clinically diagnosed VAI.

The pediatric Critical Illness Stress-induced Immune Suppression (CRISIS) trial compared the effectiveness of 2 nutraceutical supplementation strategies and found no difference in the development of nosocomial infection and sepsis in the overall population. We performed an exploratory post hoc analysis of interaction between nutraceutical treatments and host immune status related to the development of nosocomial infection/sepsis.Children from the CRISIS trial were analyzed according to 3 admission immune status categories marked by decreasing immune competence: immune competent without lymphopenia, immune competent with lymphopenia, and previously immunocompromised. The comparative effectiveness of the 2 treatments was analyzed for interaction with immune status category.There were 134 immune-competent children without lymphopenia, 79 previously immune-competent children with lymphopenia, and 27 immunocompromised children who received 1 of the 2 treatments. A significant interaction was found between treatment arms and immune status on the time to development of nosocomial infection and sepsis ( P.05) and on the rate of nosocomial infection and sepsis per 100 patient days ( P.05). Whey protein treatment protected immune-competent patients without lymphopenia from infection and sepsis, both nutraceutical strategies were equivalent in immune-competent patients with lymphopenia, and zinc, selenium, glutamine, and metoclopramide treatment protected immunocompromised patients from infection and sepsis.The science of immune nutrition is more complex than previously thought. Future trial design should consider immune status at the time of trial entry because differential effects of nutraceuticals may be related to this patient characteristic.

Study Objective. To determine the safety, effectiveness, and dosing of dexmedetomidine in intensive care infants and children who require sedation, and the rationale for patient selection. Design. Prospective observational study. Setting. Eleven-bed pediatric intensive care unit in a university-affiliated children's hospital. Patients. Seventeen infants and children who received dexmedetomidine consecutively between May 4, 2005, and May 4, 2006. Measurements and Main Results. Data were collected on demographics, blood pressure and heart rate measurements, and adverse effects. The rationale for dexmedetomidine use, its dosing, use of other sedatives, and treatment duration were also recorded. Twenty treatment courses in 17 patients (median age 5 mo, range 1 mo-17 yrs) were evaluated. Ten patients (59%) had chronic neurologic impairments (including Down syndrome in nine [53%]). Thirteen (76%) had undergone cardiac surgery, two (12%) had respiratory failure, one (6%) had endocarditis, and one (6%) had undergone scoliosis repair. In 15 (75%) of 20 cases, dexmedetomidine was started to minimize the use of midazolam before extubation; in 13 (87%) of these cases, the patients were extubated within 24 hours. The remaining patients could not tolerate midazolam, and dexmedetomidine was used as an alternative. No loading doses were given. The mean ± SD starting dose was 0.2 ± 0.2 μg/kg/hour, with a maximum of 0.5 ± 0.2 μg/kg/hour. Mean ± SD duration was 32 ± 21 hours (range 3–75 hrs); 10 courses exceeded 24 hours. Mean arterial pressures before and after starting treatment were not significantly different (p=0.76), nor were values at discontinuation (p=0.31) or 12 hours later (p=0.29). No significant differences were noted in heart rate at the start (p=0.09), at discontinuation (p=0.06), or 12 hours later (p=0.17). One patient (6%) developed hypotension; no other adverse effects were noted. Conclusion. With careful patient selection and a conservative approach to dosing, dexmedetomidine was a useful sedative in children requiring mechanical ventilation. It allowed for a reduction or elimination of other sedatives, and it was particularly useful in children with chronic neurologic impairments. Dexmedetomidine was well tolerated, with no clinically significant effects on blood pressure or heart rate.

The monitoring of the quality of patient care in today's health care environment may be best accomplished through collaborative continuous quality improvement (CQI) programs using the efforts of physicians, nurses, dietitians, and other health care professionals. The CQI Committee of the Pediatric Intensive Care Unit (PICU), a 10-bed combined medical and surgical unit, developed a collaborative CQI audit to monitor whether critically ill PICU patients should receive nutrition therapy (oral, enteral, or parenteral) in a timely manner. Timely nutrition support was defined as initiation of nutrition therapy within 72 hours of admission for previously well-nourished patients (category A) or within 48 hours of admission for patients with a history of chronic illness, malnutrition, or trauma (category B). Whether pediatric nutrition support team consultations on category B patients were completed within 72 hours of admission to the PICU also was monitored. An evaluation goal of 80% was set to meet the indicator criteria.