Ventilator-associated pneumonia in pediatric intensive care unit patients: risk factors and outcomes

Prior carbapenem exposure increases the incidence of ventilator-associated pneumonia in critically Ill children

BACKGROUND

Prior antibiotic exposure has been identified as a risk factor for VAP occurrence, making it a growing concern among clinical practitioners. But there is a lack of systematic research on the types of antibiotics and the duration of exposure that influence VAP occurrence in children at current.

METHODS

We retrospectively reviewed 278 children admitted to the Pediatric Intensive Care Unit (PICU) and underwent invasive mechanical ventilation (MV) between January 2020 and December 2022. Of these, 171 patients with MV duration ≥ 48 h were included in the study, with 61 of them developing VAP (VAP group) and the remaining 110 as the non-VAP group. We analyzed the relationship between early antibiotic exposure and VAP occurrence.

RESULTS

The incidence of VAP was 21.94% (61/278). The VAP group had significantly longer length of hospital stay (32.00 vs. 20.00 days, p<0.001), PICU stay(25.00 vs. 10.00 days, p<0.001), and duration of mechanical ventilation(16.00 vs. 6.00 days, p<0.001) compared to the non-VAP group. The mortality in the VAP group was significantly higher than that in the non-VAP group (36.07% vs. 21.82%, p = 0.044). The VAP group had a significantly higher rate of carbapenem exposure (65.57% vs. 41.82%, p = 0.003) and duration of usage (9.00 vs. 5.00 days, p = 0.004) than the non-VAP group. Vancomycin and/or linezolid exposure rates (57.38% vs. 40.00%, p = 0.029) and duration (8 vs. 4.5 days, p = 0.010) in the VAP group were significantly higher than that in the non-VAP group, either. Multivariate logistic regression analysis identified the use of carbapenem (≥ 7 days) (OR = 5.156, 95% CI: 1.881-14.137, p = 0.001), repeated intubation (OR = 3.575, 95% CI: 1.449-8.823, p = 0.006), and tracheostomy (OR = 5.767, 95% CI:1.686-19.729, p = 0.005) as the independent risk factors for the occurrence of VAP, while early intravenous immunoglobulin (IVIG) was a protective factor against VAP (OR = 0.426, 95% CI: 0.185-0.98, p = 0.045).

CONCLUSION

Prior carbapenem exposure (more than 7 days) was an independent risk factor for the occurrence of VAP. For critically ill children, reducing carbapenem use and duration as much as possible should be considered.

The Clinical Pulmonary Infection Score Combined with Procalcitonin and Lung Ultrasound (CPIS-PLUS), a Good Tool for Ventilator Associated Pneumonia Early Diagnosis in Pediatrics

Ventilator-associated pneumonia (VAP) is common in Pediatric Intensive Care Units. Although early detection is crucial, current diagnostic methods are not definitive. This study aimed to identify lung ultrasound (LUS) findings and procalcitonin (PCT) values in pediatric patients with VAP to create a new early diagnosis score combined with the Clinical Pulmonary Infection Score (CPIS), the CPIS-PLUS score. Prospective longitudinal and interventional study. Pediatric patients with suspected VAP were included and classified into VAP or non-VAP groups, based on Centers of Disease Control (CDC) criteria for the final diagnosis. A chest-X-ray (CXR), LUS, and blood test were performed within the first 12 h of admission. CPIS score was calculated. A total of 108 patients with VAP suspicion were included, and VAP was finally diagnosed in 51 (47%) patients. CPIS-PLUS showed high accuracy in VAP diagnosis with a sensitivity (Sn) of 80% (95% CI 65-89%) and specificity (Sp) of 73% (95% CI 54-86%). The area under the curve (AUC) resulted in 0.86 for CPIS-PLUS vs. 0.61 for CPIS. In conclusion, this pilot study showed that CPIS-PLUS could be a potential and reliable tool for VAP early diagnosis in pediatric patients. Internal and external validations are needed to confirm the potential value of this score to facilitate VAP diagnosis in pediatric patients.

Respiratory outcomes and survival after unplanned extubation in the NICU: a prospective cohort study from the SEPREVEN trial

OBJECTIVE

To compare reintubation rates after planned extubation and unplanned extubation (UE) in patients in neonatal intensive care units (NICUs), to analyse risk factors for reintubation after UE and to compare outcomes in patients with and without UE.

DESIGN

Prospective, observational study nested in a randomised controlled trial (SEPREVEN/Study on Epidemiology and PRevention of adverse EVEnts in Neonates). Outcomes were expected to be independent of the intervention tested.

SETTING

12 NICUs in France with a 20-month follow-up, starting November 2015.

PATIENTS

n=2280 patients with a NICU stay >2 days, postmenstrual age ≤42 weeks on admission.

INTERVENTIONS/EXPOSURE

Characteristics of UE (context, timing, sedative administration in the preceding 6 hours, weaning from ventilation at time of UE) and patients.

MAIN OUTCOME MEASURES

Healthcare professional-reported UE rates, reintubation/timing after extubation, duration of mechanical ventilation, mortality and bronchopulmonary dysplasia (BPD).

RESULTS

There were 162 episodes of UE (139 patients, median gestational age (IQR) 27.3 (25.6-31.7) weeks). Cumulative reintubation rates within 24 hours and 7 days of UE were, respectively, 50.0% and 57.5%, compared with 5.5% and 12.3% after a planned extubation. Independent risk factors for reintubation within 7 days included absence of weaning at the time of UE (HR, 95% CI) and sedatives in the preceding 6 hours (HR 1.93, 95% CI 1.04 to 3.60). Mortality at discharge did not differ between patients with planned extubation or UE. UE was associated with a higher risk of BPD.

CONCLUSION

In the SEPREVEN trial, reintubation followed UE in 58% of the cases, compared with 12% after planned extubation.

TRIAL REGISTRATION NUMBER

NCT02598609.

Continuous monitoring of endotracheal tube position with near infrared light

Significance

Endotracheal intubation is a common approach for airway management in critically ill patients. However, the position of the endotracheal tube (ETT) may be altered during the procedure due to head movements. Accidental displacement or dislodge of the ETT may reduce the airflow, leading to moderate to severe complications, and in some cases even fatality. Therefore, timely detection of changes in ETT position in the trachea is critical to ensure immediate and intermediate interventions to maintain the ETT in the proper position. Currently, there are no widely utilized tools for real-time monitoring of ETT positions.

Aim

The goal of this study is to develop a cost-effective and easy-to-use near-infrared (NIR) device, named Opt-ETT, capable of continuously monitoring the ETT position in the trachea of a patient.

Approach

A side-firing fiber is attached to the side of the ETT to illuminate the trachea tissue with NIR light, and a detector board containing five phototransistors is affixed to the chest skin to measure the intensity of diffusely transmitted light. Displacement of the ETT is estimated using second-order polynomial fitting to the ratios of the phototransistor readings. Monte Carlo simulations, ex vivo experiment on porcine tissue, and in vivo experiments using a swine model have been conducted to assess the feasibility of the device.

Results

The design of the Opt-ETT device has been verified by the Monte Carlo simulations and ex vivo experiment. The estimation of displacement from in vivo experiments using the Opt-ETT exhibited a high degree of agreement with that measured by a reference sensor, with a discrepancy between - 1.0 to + 1.5    mm within a displacement range from - 15 to + 15    mm .

Conclusions

The Opt-ETT device provides a potentially cost-effective solution for real-time and continuous monitoring of ETT position in patient during an intubation procedure.

Early-Onset Ventilator-Associated Pneumonia in Pediatric Severe Traumatic Brain Injury

BACKGROUND

Early-onset ventilator-associated pneumonia (VAP) is associated with poor outcomes in patients with severe traumatic brain injury (TBI). The primary aim of this study was to describe VAP, including the microbiology of VAP and differences in frequency of VAP when various definitions are applied. The secondary aim was to determine the clinical variables associated with the development of VAP in children with severe TBI.

METHODS

This is a retrospective cohort study at a quaternary referral children's hospital with a level I trauma center designation. Inclusion criteria were patients aged 0-18 years admitted to the pediatric intensive care unit between 2015 and 2020 with severe TBI requiring at least 2 days of invasive ventilation. VAP was defined by using Center of Disease Control (CDC) definition or clinical VAP, based on physician diagnosis. We compared general demographics, reviewed trauma and injury data, and outcomes to assess any differences between patients with VAP and non-VAP patients. Associations were tested with regression models.

RESULTS

After applying all inclusion and exclusion criteria, 90 patients were included in the analysis. Patients with VAP were older (8.5 vs. 5.6 years, P = 0.03). Patients with VAP were less likely to have suffered from abusive head trauma (P = 0.01). Patients who received continuous neuromuscular blockade or targeted temperature management did not have different frequencies of VAP. CDC-defined VAP was diagnosed in 27% of patients. Number of patients with VAP increased to 41% for physician-diagnosed or clinical VAP. Methicillin-sensitive Staphylococcus aureus was the most common isolate grown, followed by Hemophilus influenza, with most VAP occurring on days 2-5 of intubation. VAP was not associated with mortality but was associated with worse functional status scale in patients who survived to discharge (8 vs. 7.5, P = 0.048). Over a cumulative period of days, nebulized 3% and albuterol were associated with decreased incidence of VAP.

CONCLUSIONS

Ventilator-associated pneumonia occurs commonly in children with severe TBI, with rates of 27-41%, depending on CDC-defined VAP or clinical VAP. The discrepancy between clinical VAP and CDC-defined VAP further illustrates the need for a standardized definition for VAP. Although most interventions were not associated with VAP, nebulized 3% saline and albuterol were associated with reduced incidence of VAP; future investigation is needed to determine whether mucolytic agents can decrease the rate of VAP in children with severe TBI.

Risk factors for neonatal VAP: A retrospective cohort study

Ventilator-associated pneumonia (VAP) is a serious complication in neonates requiring mechanical ventilation. This study aimed to determine the risk factors associated with the development of VAP in neonates admitted to the neonatal intensive care unit (NICU) of the Affiliated Hospital of Southwest Medical University. In a retrospective observational study, neonates admitted to the NICU from 1 January 2019, to 31 December 2021, requiring ventilation for more than 48 h were included. Neonates who died within 48 h of NICU admission, those without obtainable consent, or identified with a genetic syndrome were excluded. Various neonatal and clinical variables were evaluated. Univariate and multivariate analyses were performed to determine risk factors associated with VAP. Of the total neonates included, several risk factors were identified for VAP, such as being a premature infant and use of dexamethasone and sedatives. Moreover, reintubation was found to decrease the risk of VAP. Some factors like gestational age, birth weight, Apgar scores at 5 min, and other parameters were found not significantly associated with the development of VAP. The study identified several risk factors associated with the development of VAP in neonates. Recognizing these risk factors could help in the prevention and early management of VAP, thus improving the prognosis for these patients. Further studies are needed to validate these findings and explore the mechanistic links between these factors and VAP.

Clinical Decision Support System to Detect the Occurrence of Ventilator-Associated Pneumonia in Pediatric Intensive Care

OBJECTIVES

Ventilator-associated pneumonia (VAP) is a severe care-related disease. The Centers for Disease Control defined the diagnosis criteria; however, the pediatric criteria are mainly subjective and retrospective. Clinical decision support systems have recently been developed in healthcare to help the physician to be more accurate for the early detection of severe pathology. We aimed at developing a predictive model to provide early diagnosis of VAP at the bedside in a pediatric intensive care unit (PICU).

METHODS

We performed a retrospective single-center study at a tertiary-care pediatric teaching hospital. All patients treated by invasive mechanical ventilation between September 2013 and October 2019 were included. Data were collected in the PICU electronic medical record and high-resolution research database. Development of the clinical decision support was then performed using open-access R software (Version 3.6.1®).

MEASUREMENTS AND MAIN RESULTS

In total, 2077 children were mechanically ventilated. We identified 827 episodes with almost 48 h of mechanical invasive ventilation and 77 patients who suffered from at least one VAP event. We split our database at the patient level in a training set of 461 patients free of VAP and 45 patients with VAP and in a testing set of 199 patients free of VAP and 20 patients with VAP. The Imbalanced Random Forest model was considered as the best fit with an area under the ROC curve from fitting the Imbalanced Random Forest model on the testing set being 0.82 (95% CI: (0.71, 0.93)). An optimal threshold of 0.41 gave a sensitivity of 79.7% and a specificity of 72.7%, with a positive predictive value (PPV) of 9% and a negative predictive value of 99%, and with an accuracy of 79.5% (95% CI: (0.77, 0.82)).

CONCLUSIONS

Using machine learning, we developed a clinical predictive algorithm based on clinical data stored prospectively in a database. The next step will be to implement the algorithm in PICUs to provide early, automatic detection of ventilator-associated pneumonia.

Prevalence and Etiology of Community- and Hospital-Acquired Pneumonia in Saudi Arabia and Their Antimicrobial Susceptibility Patterns: A Systematic Review

(1) Background and Objectives: Pneumonia is a major cause of morbidity and mortality worldwide, including in Saudi Arabia, and the prevalence and etiology of the disease varies depending on the setting. The development of effective strategies can help reduce the adverse impact of this disease. Therefore, this systematic review was conducted to explore the prevalence and etiology of community-acquired and hospital-acquired pneumonia in Saudi Arabia, as well as their antimicrobial susceptibility. (2) Materials and Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations were followed for this systematic review. Several databases were used to perform a thorough literature search, and papers were then assessed for eligibility by two independent reviewers. The Newcastle-Ottawa Scale (NOS) was used to extract the data from the relevant research and evaluate its quality. (3) Results: This systematic review included 28 studies that highlighted the fact that gram-negative bacteria, particularly Acinetobacter spp. and Pseudomonas aeruginosa, were the common cause of hospital-acquired pneumonia, while Staphylococcus aureus and Streptococcus spp. were responsible for community-acquired pneumonia in children. The study also found that bacterial isolates responsible for pneumonia showed high resistance rates against several antibiotics, including cephalosporins and carbapenems. (4) Conclusions: In conclusion, the study found that different bacteria are responsible for community- and hospital-acquired pneumonia in Saudi Arabia. Antibiotic resistance rates were high for several commonly used antibiotics, highlighting the need for rational antibiotic use to prevent further resistance. Moreover, there is a need to conduct more regular multicenter studies to assess etiology, resistance, and susceptibility patterns of pneumonia-causing pathogens in Saudi Arabia.

Ventilator-Associated Pneumonia in Paediatric Intensive Care Unit Patients: Microbiological Profile, Risk Factors, and Outcome

Introduction Ventilator-associated pneumonia (VAP) is one of the dreaded events in sick children who are ventilated in the paediatric intensive care unit (PICU) and has a high mortality rate. So, there is a need to know the causative organisms, risk factors, and possible predictors in a particular PICU for prevention, early identification, and treatment to decrease morbidity and mortality. This study was planned with the objectives to determine the microbiological profile, associated risk factors, and outcome of VAP in children. Methods In this observational cross-sectional study conducted at Dr. B C Roy Post Graduate Institute of Paediatric Science, Kolkata, India, 37 VAP cases were diagnosed using clinical pulmonary infection score >6 and confirmed by tracheal culture and X-ray. Results The number of paediatric patients suffering from VAP was 37 (36.2%). The commonest age group involvement was one to five years. The microbiological profile included Pseudomonas aeruginosa (29.8%) and Klebsiella pneumoniae (21.6%) as the commonest organisms followed by Staphylococcus aureus (18.9%) and Acinetobacter (13.5%). The factors significantly associated with the increased frequency of VAP were the use of steroids, sedation, and reintubation. The mean duration of mechanical ventilation (MV) in VAP was 15 days compared to non-VAP (seven days), and the longer duration of ventilation was significantly associated with VAP (p=0.00001). Mortality in VAP was 48.54% compared to non-VAP (55.84%) with no significant association (p=0.0843) of VAP with death occurrence. Conclusion The present study showed that VAP occurrence is associated with prolonged duration of MV, PICU stay, and hospital stay but is not significantly associated with mortality. It also indicated that gram-negative bacteria were the most common VAP causative organisms in this cohort.

Closed versus open endotracheal tube suction in mechanically ventilated neonates: a randomized controlled trial

This study aimed to evaluate the effect of closed versus open endotracheal tube suction in reducing ventilator-associated pneumonia in mechanically ventilated neonates. In this open-label, parallel-group, randomized controlled trial with allocation concealment, ventilated neonates (≥ 28 weeks and ≥ 800 g) were either allocated to the closed-suction group (n = 41) or open-suction group (n = 39). The ventilator circuit of the babies enrolled in the closed-suction group was attached to the closed-suction catheter on the requirement of their first suction, and it was changed after every 48 h or earlier if visibly soiled whereas babies enrolled in the open-suction group were suctioned with a new suction catheter each time they require suction. The primary outcome was the incidence of VAP per 1000 days. Baseline maternal and neonatal characteristics were comparable between the two groups. The proportion of neonates with VAP in the closed-suction group was 3 (7.3%) and 1 (2.6%) in the open-suction group with an RR of 2.8 (95% CI: 0.30-26.28) and a p-value of 0.35. The incidence of VAP in the closed-suction group was 3.9 per 1000 ventilator days and 1.3 per 1000 ventilator days in the open-suction group. The incidence of clinical VAP/1000 ventilator days was 33.63 ± 22.96 in the closed-suction group and 28.67 ± 12.32 in the open-suction group with a mean difference of 5 (95% CI: - 3.26 to 13.26) and p-value of 0.24.

CONCLUSION

In a unit with a low incidence of VAP, the effect of the endotracheal suction method alone did not impact the occurrence of VAP in the study population.

CLINICAL TRIAL REGISTRATION

CTRI/2020/03/023679; Date: 17.02.2020.

WHAT IS KNOWN

• Better physiological stability of the closed-suctioning method on short-term measures including noticeably fewer episodes of hypoxia, a smaller drop in TcPO2 levels, and less variability in heart rate and bradycardia episodes.

WHAT IS NEW

• In a unit with a low incidence of VAP in the neonates, randomized control trial studying the effect of the endotracheal suction method alone did not impact the occurrence of VAP amongst the study population.

Targeted temperature management at 36°C is a risk factor for ventilator-associated pneumonia

BACKGROUND

In contrast to the adult population, limited information is currently available on risk factors for ventilator-associated pneumonia (VAP) in children. Therapeutic hypothermia has been identified as a risk factor for the early onset of VAP in adults; however, the relationship between VAP and normothermia remains unclear. The present study investigated risk factors for VAP in children, with a focus on the deleterious effects of therapeutic normothermia on VAP.

METHODS

We retrospectively investigated the clinical characteristics of children treated with mechanical ventilation for more than 48 h and analyzed risk factors for VAP. The endpoint was the onset of VAP by the seventh day after the initiation of mechanical ventilation.

RESULTS

Among the 288 patients enrolled, seven (2.4%) developed VAP. No significant differences were observed in clinical backgrounds between the VAP and non-VAP groups. A univariate analysis identified target temperature management (TTM) at 36°C (p < 0.0001) and methylprednisolone (mPSL) pulse therapy (p = 0.02) as risk factors for VAP. An analysis of the time to the onset of VAP by the Kaplan-Meier plot and log-rank test revealed a significantly higher incidence of VAP in the TTM group (p < 0.0001) and mPSL pulse group (p = 0.001).

CONCLUSION

TTM at 36°C and mPSL pulse therapy may be risk factors for VAP in the pediatric population.

Anti-Inflammatory and Anti-Bacterial Effects of Mouthwashes in Intensive Care Units: A Systematic Review and Meta-Analysis

Mouthwashes are used as oral care for critical care patients to prevent infections. However, there are conflicting data concerning whether mouthwashes are needed as a part of daily oral care for critical care patients. This study aimed to evaluate the anti-inflammatory and anti-bacterial effects of mouthwashes for critical care patients. The PubMed, EMBASE, CENTRAL, and grey literature databases were searched by descriptors combining population (intensive care unit patients) and intervention (mouthwashes). After the screening, only randomized controlled trials (RCTs) evaluating the anti-inflammatory and anti-bacterial effects of mouthwashes in patient critical care were included. From the 1531 articles, 16 RCTs satisfied the eligibility criteria for systematic review and 10 were included in the meta-analyses. A significant difference was found in the incidence of ventilator associated pneumonia (VAP) (odds ratio [OR] 0.53, 95% confidential interval [95% CI] 0.33 to 0.86) between the mouthwash and placebo groups, while no significant difference was found in the mortality (OR 1.49, 95%CI 0.92 to 2.40); the duration of mechanical ventilation (weighted mean difference [WMD] -0.10, 95%CI -2.01 to 1.81); and the colonization of Staphylococcus aureus (OR 0.88, 95%CI 0.34 to 2.30), Escherichia coli (OR 1.19, 95%CI 0.50 to 2.82), and Pseudomonas aeruginosa (OR 1.16, 95%CI 0.27 to 4.91) between the two groups. In conclusion, mouthwashes were effective in decreasing the incidence of VAP. Thus, mouthwashes can be used as part of daily oral care for critical care patients.

Ventilator-Associated Pneumonia Prevention in Pediatric Patients: Narrative Review

Ventilator-associated pneumonia (VAP), one of the most common healthcare-associated infections in intensive care settings, is associated with significant morbidity and mortality. VAP is diagnosed in >10% of patients on mechanical ventilation, incidence rising with number of ventilator days. In recent decades, the pathophysiology of VAP, VAP risk factors and treatment have been extensively studied. In critically ill pediatric patients, mechanical issues such as insufficient tightness of the ventilator circuit (mainly due to historically based preference of uncuffed tubes) and excessive humidity in the circuit are both significant risk factors of VAP development. Protocol-based approaches to critically ill patients on mechanical ventilation, closed suctioning, upper body position, enteral feeding and selective gastric acid suppression medication have a beneficial effect on VAP incidence. In recent decades, cuffed tubes applied to the whole spectrum of critically ill pediatric patients (except neonates <2700 g of weight), together with cuff-oriented nursing care including proper cuff-pressure (<20 cm H2O) management and the use of specialized tracheal tubes with subglottic suction ports combined with close infraglottic tracheal suctioning, have been implemented. The aim of this review was to summarize the current evidence-based knowledge about the pathophysiology, risk factors, diagnosis, treatment and prevention of VAP in clinically oriented settings.

Organizational Risk Factors and Clinical Impacts of Unplanned Extubation in the Neonatal Intensive Care Unit

OBJECTIVES

To assess the association between organizational factors and unplanned extubation events in the neonatal intensive care unit (NICU) and to evaluate the association between unplanned extubation event and bronchopulmonary dysplasia (BPD) among infants born at <29 weeks of gestational age.

STUDY DESIGN

This is a retrospective cohort study of infants admitted to a tertiary care NICU between 2016 and 2019. Nursing provision ratios, daily nursing overtime hours/total nursing hours ratio, and unit occupancy were compared between days with and days without unplanned extubation events. The association between unplanned extubation events (with and without reintubation) and the risk of BPD was evaluated in infants born at <29 weeks who required mechanical ventilation using a propensity score-matched cohort. Multivariable logistic regression analysis was used to assess the association between exposures and outcomes while adjusting for confounders.

RESULTS

On 108 of 1370 days there was ≥1 unplanned extubation event for a total of 116 unplanned extubation event events. Higher median nursing overtime hours (20 hours vs 16 hours) and overtime ratios (3.3% vs 2.5%) were observed on days with an unplanned extubation event compared with days without an unplanned extubation event (P = .01). Overtime ratio was associated with higher adjusted odds of a unplanned extubation event (aOR, 1.09; 95% CI, 1.01-1.18). In the subgroup of infants born at <29 weeks, those with an unplanned extubation event who were reintubated had a longer postmatching duration of mechanical ventilation (aOR, 13.06; 95% CI, 4.88-37.69) and odds of BPD (aOR, 2.86; 95% CI, 1.01-8.58) compared with those without an unplanned extubation event.

CONCLUSIONS

Nursing overtime ratio is associated with an increased number of unplanned extubation events in the NICU. In infants born at <29 weeks of gestational age, reintubation after an unplanned extubation event is associated with a longer duration of mechanical ventilation and increased risk of BPD.

RISK score for developing ventilator-associated pneumonia in children: The RISVAP study

OBJECTIVES

Ventilator-associated pneumonia (VAP) is the second most common healthcare-associated infection in children. The aim of this study was to determine the risk factors for VAP in children and to create a risk score for developing VAP (RISVAP score).

STUDY DESIGN

It was a prospective observational study, including children who required mechanical ventilation (MV), registered in the multicentre ENVIN-HELICS database from 2014 to 2019. The regression coefficients of each independent risk factor for VAP were used to create the RISVAP score. Each factor scored 0 if it was absent, or, if it was present, an assigned value from 1 to 7, according to the regression coefficient.

RESULTS

A total of 3798 patients were included, 97(2.5%) developing VAP. The independent risk factors for VAP were: female (odds ratio [OR]: 1.642, p = 0.024), MV > 4 days (OR: 26.79, p < 0.001), length in pediatric intensive care unit > 7 days (OR: 11.74, p < 0.001), and previous colonisation (OR: 4.18, p < 0.001). The RISVAP was calculated for each patient as the sum of all the independent risk factors. Three risk groups were obtained: low (0-5 points), intermediate (6-12 points), and high risk for VAP (13-16 points). The area under the curve for the final score was 0.905 (95%confidence interval: 0.888-0.923, p < 0.001).

CONCLUSIONS

The RISVAP is the first risk score for VAP in pediatric populations. Using this predictive score, might be helpful to detect vulnerable patients and therefore implement preventative strategies.

Point-of-Care Gastric Ultrasound Confirms the Inaccuracy of Gastric Residual Volume Measurement by Aspiration in Critically Ill Children: GastriPed Study

Introduction

No consensus exists on how to define enteral nutrition tolerance in critically ill children, and the relevance of gastric residual volume (GRV) is currently debated. The use of point-of-care ultrasound (POCUS) is increasing among pediatric intensivists, and gastric POCUS may offer a new bedside tool to assess feeding tolerance and pre-procedural status of the stomach content.

Materials and Methods

A prospective observational study was conducted in a tertiary pediatric intensive care unit. Children on mechanical ventilation and enteral nutrition were included. Gastric POCUS was performed to assess gastric contents (empty, full of liquids or solids), and gastric volume was calculated as per the Spencer formula. Then, GRV was aspirated and measured. The second set of gastric POCUS measurements was performed, similarly to the first one performed prior to GRV measurement. The ability of GRV measurement to empty the stomach was compared to POCUS findings. Both GRV and POCUS gastric volumes were compared with any clinical signs of enteral feeding intolerance (vomiting).

Results

Data from 64 children were analyzed. Gastric volumes were decreased between the POCUS measurements performed pre- and post-GRV aspiration [full stomach, n = 59 (92.2%) decreased to n = 46 (71.9%), p =0.001; gastric volume: 3.18 (2.40-4.60) ml/kg decreased to 2.65 (1.57-3.57), p < 0.001]. However, the stomach was not empty after GRV aspiration in 46/64 (71.9%) of the children. There was no association between signs of enteral feeding intolerance and the GRV obtained, nor with gastric volume measured with POCUS.

Discussion

Gastric residual volume aspiration failed to empty the stomach and appeared unreliable as a measure of gastric emptiness. Gastric POCUS needs further evaluation to confirm its role.

Outcome of Ventilator-Associated Pneumonia in Children Post Cardiac Surgery: A Prospective Observational Study

Background Ventilator-associated pneumonia (VAP) is a serious complication in post congenital cardiac repair in children leading to high morbidity and mortality. We conducted this study with an aim to determine incidence, risk factors, and mortality of VAP in pediatric cardiac surgical patients.

Methodology This prospective observational study included 371 children aged less than 12 years who underwent elective cardiac surgery for congenital heart disease from March 2020 to September 2021. Patients were categorized into two groups: those with VAP and without VAP.

Results Out of 371 patients, 67 patients (18%) developed VAP. The VAP incidence density was 36.3 episodes per 1,000 mechanical ventilation days. Age less than 1 year (p <0.001), prolonged preoperative hospital stay (odds ratio: 2.25; 95% CI:1.11–4.52; p = 0.007), and higher RACHS1 (risk adjustment in congenital heart surgery) category, prolonged invasive mechanical ventilation (p <0.001), delayed sternal closure, tracheostomy, reintubation, use of uncuffed ET tube, and peritoneal dialysis were associated with higher incidence of VAP. Total 86 tracheal samples were taken. Most frequently isolated microorganisms were Acinetobacter baumannii (43%) and Klebsiella pneumoniae (23%). Antibiotic resistance was alarming as Acinetobacter and Klebsiella species were highly resistant to commonly used broad spectrum antibiotics like cephalosporins, aminoglycosides, and carbapenems.

Conclusion VAP incidence in our study was 18% and VAP incidence density was 36.3 per 1,000 mechanical ventilation days. Patients with VAP had higher mortality (32%) as compared with patients without VAP (12%).

Risk factors for healthcare-associated infection among children in a low-and middle-income country

BACKGROUND

Healthcare-associated infections (HAI) are one of significant causes of morbidity and mortality. Evaluating risk factors associated with HAI are important to improve clinical outcomes. We aimed to evaluate the risk factors of HAI in children in a low-to middle-income country.

METHODS

A prospective cohort study was conducted during 43 months at a teaching hospital in Yogyakarta, Indonesia. All consecutive patients admitted to pediatric ICU and pediatric wards > 48 h were eligible. Those eligible patients were observed daily to identify the presence of HAI based on CDC criteria. The risk factors of HAI were identified. Multivariable logistic regression was used to identify independent risk factors.

RESULTS

Total of 2612 patients were recruited. Of 467 were diagnosed as HAI. The cumulative incidence of HAI was 17.9%. In the multivariable analysis; length of stay > 7 days, severe sepsis, use of urine catheter, central venous catheter (CVC), non-standardized antibiotics, and aged < 1 year were independently associated with increased risk of HAI with adjusted OR (95%CI): 5.6 (4.3-7.3), 1.9 (1.3-2.9), 1.9 (1.3-2.6), 1.8 (1.1-2.9), 1.6 (1.2-2.0), and 1.4 (1.1-1.8), respectively.

CONCLUSIONS

This study found that length of stay > 7 days, use of urine catheter and CVC, non-standardized antibiotic use, aged < 1 year, and had a diagnosis of severe sepsis increased risk of HAI.

Evaluation of the applicability of the current CDC pediatric ventilator-associated events (PedVAE) surveillance definition in the neonatal intensive care unit population

Background

There is limited data on pediatric ventilator-associated events (PedVAE) in the neonatal intensive care unit (NICU) setting, since the CDC mandated state reporting of these events in January 2019. This study sought to describe PedVAE rates and characteristics in the NICU population.

Methods

Single-center case-control study of infants requiring mechanical ventilation in a 39-bed level IV NICU between January 1, 2018 and December 31, 2020. Baseline infant demographic, respiratory support and antibiotic use data was obtained and comparisons were performed between patients with potential PedVAEs and those without events.

Result

Two hundred and nine infants were mechanically ventilated. Two of the 126 patients ventilated for ≥4 days met CDC criteria for PedVAEs with a total of 3 events, and 32 (25%) received antibiotics with escalation of respiratory support, primarily for tracheitis.

Conclusion

NICU-specific data on PedVAE is limited. Only 2 infants in the study period met the current CDC criteria for PedVAE with a rate of 0.9 events per 1000 ventilator days. The current CDC PedVAE definition might be inadequate to identify actionable VAEs to inform prevention efforts in the NICU population, and alternate indices could better characterize these events.

Ventilator-Associated Pneumonia in Neonates Admitted to a Tertiary Care NICU in Bulgaria

Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection (HAI) among neonatal patients in the intensive care units (ICUs) and is a serious challenge for neonatologists because it affects critically ill patients who need prolonged mechanical ventilation. In Bulgaria, there is no detailed data at regional and national levels on the characteristics of VAP in newborns, which imposes a necessity for specific studies of risk factors and etiology of VAP. The aim of the study was to analyze the frequency, characteristics and risk factors for the occurrence of VAP in newborns hospitalized in intensive care unit. This was a prospective study, conducted between January 2017 and June 2018 in the NICU of University Hospital "St. George" Plovdiv, Bulgaria. The sample consisted of 507 neonates, followed up prospectively, 107 of whom were placed on mechanical ventilation for ≥48 h. VAP was diagnosed in 33 out of 107 neonates (31%). The VAP incidence rate was 35.06/1.000 ventilator days. We confirmed differences between the median birth weight (1,310 vs. 1,690 g, p = 0.045) and average gestational age (31.08 g.w. vs. 33.08 g.w, p = 0.04) of the patients with and without VAP. The average stay of patients with VAP in the NICU was statistically significantly longer than the hospital stay of non-VAP patients (35.70 ± 21.84 days vs. 21.77 ± 17.27 days (t = 3.241, p = 0.002). In neonates with VAP, the duration of mechanical ventilation was statistically significantly longer compared with non-VAP patients (16.88 ± 11.99 vs. 5.42 ± 4.48; t = 5.249, p = 0.000). A statistically significant prevalence of Gram-negative bacteria among VAP patients was demonstrated (91%) compared to the Gram-positive (9%), p < 0.05. The leading causative agent of VAP was Klebsiella pneumoniae ESBLs + (27%), followed by Acinetobacter baumannii (14%), Pseudomonas aeruginosa (12%) and Escherichia coli (12%). In multivariate logistic regression, mechanical ventilation >7 days was established as an independent risk factor for VAP (OR 3.6; 95% CI: 1.7-6.5, p = 0.003). VAP remains a serious and outstanding issue in pediatric and neonatal intensive care units. The findings of the current study emphasize that the birth weight, gestational age, and duration of hospital stay have a significant association with ventilator-associated pneumonia.

Planned Peri-Extubation Fasting in Critically Ill Children: An International Survey of Practice

INTRODUCTION

Cumulative energy/protein deficit is associated with impaired outcomes in pediatric intensive care Units (PICU). Enteral nutrition is the preferred mode, but its delivery may be compromised by periods of feeding interruptions around procedures, with peri-extubation fasting the most common procedure. Currently, there is no evidence to guide the duration of the peri-extubation fasting in PICU. Therefore, we aimed to explore current PICU fasting practices around the time of extubation and the rationales supporting them.

MATERIALS AND METHODS

A cross sectional electronic survey was disseminated via the European Pediatric Intensive Care Society (ESPNIC) membership. Experienced senior nurses, dieticians or doctors were invited to complete the survey on behalf of their unit, and to describe their practice on PICU fasting prior to and after extubation.

RESULTS

We received responses from 122 PICUs internationally, mostly from Europe. The survey confirmed that fasting practices are often extrapolated from guidelines for fasting prior to elective anesthesia. However, there were striking differences in the duration of fasting times, with some units not fasting at all (in patients considered to be low risk), while others withheld feeding for all patients. Fasting following extubation also showed large variations in practice: 46 (38%) and 26 (21%) of PICUs withheld oral and gastric/jejunal nutrition more than 5 h, respectively, and 45 (37%) started oral feeding based on child demand. The risk of vomiting/aspiration and reducing nutritional deficit were the main reasons for fasting children [78 (64%)] or reducing fasting times [57 (47%)] respectively.

DISCUSSION

This variability in practices suggests that shorter fasting times might be safe. Shortening the duration of unnecessary fasting, as well as accelerating the extubation process could potentially be achieved by using other methods of assessing gastric emptiness, such as gastric point of care ultrasonography (POCUS). Yet only half of the units were aware of this technique, and very few used it.

Characteristics and Outcomes of Mechanically Ventilated Pediatric Patients in A Tertiary Referral Hospital, Addis Ababa, Ethiopia: Cross Sectional Study

Background

A few studies are available from Africa on the use of mechanical ventilation (MV) in the pediatric intensive care unit (PICU). Knowledge of the outcome of patients on MV is critical for better use of resources. We aimed to assess the characteristics and outcomes of mechanically ventilated pediatric patients in Tikur Anbessa Specialized Referral Hospital, Addis Ababa, Ethiopia.

Methods

A cross-sectional study was done from September 2016 to February 2018. Data were reviewed from the patients' medical records. SPSS version 21 software was used for data entry and analysis.

Results

There were 536 patients admitted to PICU; out of these, 202 (41.2%) were on MV. Sixty-three-point six percent of the participants were males and 130 (59.1%) died. The most common indications for the initiation of MV were respiratory problems 46 (20.9%) and 30.59/1000 ventilator days developed complications. Ventilator-associated pneumonia accounted for 18.6% of the complications with 20.9/1000 ventilator days. Survival of medical cases was better than the surgical cases (including trauma); [AOR= 0.13, 95% CI (0.04–0.41)] and those who have MV for more than 3 days are 79% more likely to die (p=0.003). Those who have multi-organ dysfunction syndrome (MODS) [AOR= 0.181, 95% CI (0.08, 0.412)] and high PIM II severity score [AOR= 35, 95% CI (1.7,11)] had higher mortality rate.

Conclusions

higher PIM II score, MODS, length of stay, and being a surgical patient increased the risk of mortality. Early resuscitation and thorough follow up of these ventilated patients are necessary.

Oral mucosal mouthwash with chlorhexidine does not reduce the incidence of ventilator-associated pneumonia in critically ill children: A randomised controlled trial

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most frequently encountered causes of hospital-acquired infection and results in high morbidity among intubated patients. Few trials have investigated the efficacy of oral care with chlorhexidine (CHX) mouthwash for the prevention of VAP in the paediatric population.

OBJECTIVES

The objective of this study was to assess the efficacy of CHX mouthwash in the prevention of VAP and to determine risk factors for VAP in children aged 1 month to 18 years admitted to the paediatric intensive care unit (PICU).

METHODS

This was a prospective, randomised, controlled, double-blind trial performed in the PICU. Patients were randomised into two groups receiving CHX (0.12%) (n = 88) or placebo (0.9% NaCl) (n = 86) and were followed up for VAP development. The main outcome measures were incidence of VAP, duration of hospital stay, duration of PICU stay, duration of ventilation, mortality, and the characteristics of organisms isolated in cases with VAP.

RESULTS

No difference was observed in the incidence of VAP and the type and distribution of organisms in the two groups (p > 0.05). In the CHX and placebo groups, we identified 21 and 22 patients with VAP, respectively. Incidence per 1000 ventilation days was 29.5 events in the CHX group and 35.1 events in the placebo group. Gram-negative bacteria were most common (71.4% in CHX vs. 54.5% in placebo). The use of 0.12% CHX did not influence hospital stay, PICU stay, ventilation, and mortality (p > 0.05). Multivariate analysis identified duration of ventilation as the only independent risk factor for VAP (p = 0.001).

CONCLUSION

The use of 0.12% CHX did not reduce VAP frequency among critically ill children. The only factor that increased VAP frequency was longer duration on ventilation. It appears that low concentration of CHX is not effective for VAP prevention, especially in the presence of multiresistant bacteria. CLINICALTRIALS.

GOV IDENTIFIER

NCT04527276.

Temporal airway microbiome changes related to ventilator-associated pneumonia in children

We sought to determine whether temporal changes in the lower airway microbiome are associated with ventilator-associated pneumonia (VAP) in children.Using a multicentre prospective study of children aged 31 days to 18 years requiring mechanical ventilation support for >72 h, daily tracheal aspirates were collected and analysed by sequencing of the 16S rRNA gene. VAP was assessed using 2008 Centers for Disease Control and Prevention paediatric criteria. The association between microbial factors and VAP was evaluated using joint longitudinal time-to-event modelling, matched case-control comparisons and unsupervised clustering.Out of 366 eligible subjects, 66 (15%) developed VAP at a median of 5 (interquartile range 3-5) days post intubation. At intubation, there was no difference in total bacterial load (TBL), but Shannon diversity and the relative abundance of Streptococcus, Lactobacillales and Prevotella were lower for VAP subjects versus non-VAP subjects. However, higher TBL on each sequential day was associated with a lower hazard (hazard ratio 0.39, 95% CI 0.23-0.64) for developing VAP, but sequential values of diversity were not associated with VAP. Similar findings were observed from the matched analysis and unsupervised clustering. The most common dominant VAP pathogens included Prevotella species (19%), Pseudomonas aeruginosa (14%) and Streptococcus mitis/pneumoniae (10%). Mycoplasma and Ureaplasma were also identified as dominant organisms in several subjects.In mechanically ventilated children, changes over time in microbial factors were marginally associated with VAP risk, although these changes were not suitable for predicting VAP in individual patients. These findings suggest that focusing exclusively on pathogen burden may not adequately inform VAP diagnosis.

Twenty-Four-Hour Esophageal pH Measurement in Mechanically Ventilated Children: A Prospective Cohort Study

OBJECTIVES

To assess the prevalence of gastroesophageal reflux in mechanically ventilated children using 24-hour esophageal pH-metry and its role as a risk factor for ventilator-associated pneumonia.

DESIGN

Prospective cohort study.

SETTING

PICU of a tertiary care hospital from North India.

PATIENTS

Mechanically ventilated children 1-15 years old in PICU from July 2015 to June 2017, excluding those receiving acid suppressants, known cases of gastroesophageal reflux disease, having upper gastrointestinal bleed.

INTERVENTION

Demographic details, baseline investigations, diagnosis, treatment details, and Pediatric Risk of Mortality III score were recorded at enrollment. Gastroesophageal reflux was evaluated using 24-hour esophageal pH-metry. Children were followed up for 7 days or 48 hours after extubation for development of ventilator-associated pneumonia using Centers for Disease Control and Prevention criteria. Pathologic acidic gastroesophageal reflux was defined as fall in esophageal pH less than 4 for more than 4% of total time, whereas pathologic alkaline gastroesophageal reflux as rise in esophageal pH greater than 7 for more than 17% of total time.

MEASUREMENTS AND MAIN RESULTS

Sixty-one children (median [interquartile range], age 73 mo [30-132 mo]; 44 boys [72%]) were enrolled. Median Pediatric Risk of Mortality III score was 10.0 (3-16). Median duration of ventilation was 6 days (3-9 d). Pathologic gastroesophageal reflux (acidic or alkaline) was present in 47 children (77%). Twelve children (19.7%) met criteria for pathologic acidic gastroesophageal reflux, whereas 44 children (72.1%) had pathologic alkaline gastroesophageal reflux; nine children (14.7%) had both pathologic acidic and alkaline gastroesophageal reflux. Of the enrolled children, 17 (27.9 %) developed ventilator-associated pneumonia. No patient had both pathologic acidic gastroesophageal reflux and ventilator-associated pneumonia. Of 17 children who developed ventilator-associated pneumonia, 12 (70.5%) had pathologic alkaline gastroesophageal reflux as compared to 32 children (72.7%) among the 44 children who did not develop ventilator-associated pneumonia (p = 0.87).

CONCLUSIONS

The current study shows high incidence of gastroesophageal reflux on 24-hour esophageal pH-metry in mechanically ventilated children with medical diagnoses. The significance of this finding and its impact on ventilator-associated pneumonia and other ventilator-associated events need to be examined in larger studies.

Oropharyngeal colostrum therapy reduces the incidence of ventilator-associated pneumonia in very low birth weight infants: a systematic review and meta-analysis

BACKGROUND

Oropharyngeal colostrum (OC) is a novel feeding strategy to prevent complications of prematurity. A meta-analysis was conducted to investigate whether very low birth weight infants (VLBWs) can benefit from OC.

METHODS

Randomized controlled trials (RCTs) were searched from Embase, PubMed, Web of Science, and Cochrane Central Register of Controlled Trials from the date of inception until May 2019. RCTs were eligible if they used OC therapy on VLBW infants. The primary outcomes included ventilator-associated pneumonia (VAP), necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), late-onset sepsis, and death. The secondary outcomes included the time of full enteral feeding and the length of stay.

RESULTS

Eight RCTs involving 682 patients (OC group: 332; non-OC group: 350) were included in the meta-analysis. The results suggested that OC was associated with a significantly reduced incidence of VAP [odds ratio (OR) = 0.39, 95% confidence interval (CI): 0.17-0.88, P = 0.02] and full enteral feeding days (mean difference = -2.66, 95% CI: -4.51 to -0.80, P = 0.005), a potential significance of NEC (OR = 0.51, 95% CI: 0.26-0.99, P = 0.05), a trend toward downregulating mortality (OR = 0.60, 95% CI: 0.34-1.08, P = 0.09) and proven sepsis (OR = 0.64, 95% CI: 0.40-1.01, P = 0.06).

CONCLUSIONS

OC could significantly reduce the occurrence of VAP, and consequently, its routine use should be considered for VLBWs to prevent infectious diseases.

IMPACT

OC significantly reduces the occurrence of VAP and NEC in VLBW infants. OC may reduce the incidence of VAP and NEC by increasing IgA levels. Early OC therapy for mechanical ventilation of low-weight infants may prevent the occurrence of VAP.

Incidence and risk factors for hospital-acquired infection among paediatric patients in a teaching hospital: a prospective study in southeast Ethiopia

OBJECTIVES

In order to maximise the prevention of hospital-acquired infections (HAIs) and antimicrobial resistance, data on the incidence of HAIs are crucial. In Ethiopia, data about the occurrence of HAIs among hospitalised paediatric patients are lacking. We aim to determine the incidence and risk factors of HAIs among paediatric patients in Ethiopia.

DESIGN

A prospective cohort study.

SETTING

A teaching hospital in southeast Ethiopia.

PARTICIPANTS

448 hospitalised paediatric patients admitted between 1 November 2018 and 30 June 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incidence and risk factors of hospital-acquired infections.

RESULTS

A total of 448 paediatric patients were followed for 3227 patient days. The median age of the patients was 8 months (IQR: 2-26 months). The incidence rate of HAIs was 17.7 per 1000 paediatric days of follow-up; while the overall cumulative incidence was 12.7% (95% CI 9.8% to 15.8%) over 8 months. Children who stayed greater than 6 days in the hospital (median day) (adjusted risk ratio (RR): 2.58, 95% CI 1.52 to 4.38), and children with underlying disease conditions of severe acute malnutrition (adjusted RR: 2.83, 95% CI 1.61 to 4.97) had higher risks of developing HAIs.

CONCLUSIONS

The overall cumulative incidence of HAIs was about 13 per 100 admitted children. Length of stay in the hospital and underlying conditions of severe acute malnutrition were found to be important factors associated with increased risk of HAIs.

Endotracheal cuff pressures in the PICU: Incidence of underinflation and overinflation

BACKGROUND

While uncuffed endotracheal tubes have been traditionally used in the pediatric intensive care unit (PICU) population, evidence suggests cuffed endotracheal tubes (ETTs) are also safe to use within this population. Nevertheless, risks related to the use of cuffed ETTs increase when guidelines for safe and appropriate use are not followed. The primary goal of this study was to measure the cuff pressure (CP) using a cuff pressure manometer in a group of intubated pediatric subjects and determine the rate of cuff underinflation (<20 cm H₂0) or overinflation (>30 cm H₂0). The secondary aim was to determine whether CP was associated to gender, age, ETT size, and PICU length of stay prior to CP measurement.

METHODS

This was a prospective observational study conducted in an urban PICU. Pediatric subjects intubated with cuffed ETTs from 1 April 2017 to 1 May 2017 were included in the study. ETT CPs were measured daily to determine degree of inflation and compared according to gender, age, ETT size, and number of days intubated prior to CP measurement. Descriptive data are expressed as means and standard deviations. A two-sample t test was used to compare groups according to age, gender, and number of days present. And significance was considered with a P < 0.05. Pearson chi test was used to evaluate correlation between CPs and size of the ETT, number of days intubated prior to CP measurement, gender, and age.

RESULTS

Twenty pediatric subjects admitted during the study period were included for analysis. Eleven cuff measurements were found to be within normal limits, while 9 cuff measurements were found to be underinflated. No cases of overinflation were found. There were no significant associations between CP and size of the ETT (r = -0.08), number of days intubated prior to CP measurement (r = 0.19), gender (r = 0.09), and age (r = 0.12).

CONCLUSIONS

Our study suggests that endotracheal cuff underinflation occurs often in the PICU population. Strategies to ensure appropriate ETT CPs are maintained are essential in the intubated pediatric population. Additional studies are necessary to develop interventions and training focused on the use of a cuff pressure manometer to measure CPs in the PICU by respiratory therapists and ensure consistent measurement using inter rater evaluation processes are needed.

The Incidence of Laryngotracheal Stenosis in Neonates With a History of Ventilator-Associated Pneumonia

OBJECTIVES/HYPOTHESIS

Neonatal patients requiring prolonged intubation are susceptible to both infection and laryngotracheal stenosis (LTS). This study investigated the effect of ventilator-associated pneumonia (VAP) on the development of LTS in neonates.

STUDY DESIGN

Retrospective case-control study.

METHODS

The incidence of LTS in neonates with VAP was compared with the incidence of LTS in matched intubated controls without VAP. Patients were treated at a tertiary-care medical center from 2004 to 2014. Eligible patient records were assessed for the development of LTS. Demographics, medical comorbidities, infection characteristics, and treatment variables were compared using unpaired t test or χ² test. Statistical significance was set a priori at P < .05.

RESULTS

When comparing the VAP patients with matched non-VAP controls, we found no significant differences in the incidence of LTS (VAP vs. non-VAP, 8.3% vs. 6.7%; P = .73). In subgroup analysis of the VAP cohort, LTS and non-LTS patients demonstrated similar VAP organisms on broncho-alveolar lavage (Klebsiella pneumoniae, Pseudomonas aeroginosa, Escherichia coli, methicillin-resistant Staphylococcus aureus, Streptococcus pneumoniae, and Enterobacter). Additionally, within the VAP cohort, LTS and non-LTS patients showed similar gestational age (LTS vs. non-LTS, 31.3 days vs. 28.1 days; P = .22), birth weight (LTS vs. non-LTS, 1.6 kg vs. 1.2 kg; P = .33), and similar intubation duration (LTS vs. non-LTS, 37.8 days vs. 27.5 days; P = .52).

CONCLUSIONS

In this neonatal cohort, VAP was not associated with an increased incidence of LTS. Given severity of the burden of LTS on the healthcare system, multi-institutional longitudinal investigation into contributing risk factors for neonatal LTS is warranted.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:2252-2255, 2020.

Extubation Failure and Tracheostomy Placement in Children with Acute Neurocritical Illness

BACKGROUND

There is a lack of data describing the risk factors for extubation failure (EF) or tracheostomy placement in pediatric neurocritical care (NCC) patients.

METHODS

A retrospective chart review of children admitted to the pediatric intensive care unit who were intubated for >24 h with an acute neurocritical illness and had an extubation attempt. Bivariate and multivariate statistical analysis was performed to determine significant associations of demographic, neurologic, pulmonary, and clinical variables with EF and tracheostomy placement. Analysis of predictive factors for EF (within 48 h) and tracheostomy placement during the hospitalization was conducted on a first extubation attempt group (n = 193) and a second attempt group (n = 23) who experienced either EF or a "late re-intubation" (>48 h-7 days).

RESULTS

Traumatic brain injury (37.3%) and seizures/status epilepticus (31.4%) were the most common diagnoses with neuromuscular weakness patients having the highest risk for EF and tracheostomy placement. EF occurred in 20/193 (10.4%) patients after their first attempt and 6/23 (26.1%) after a second attempt. Compared to those with a fair/strong cough, patients with a weak/absent cough had a relative risk (RR) of 9.4 for EF (95% CI, 4.9-17.9, p < 0.001) and 6.7 (95% CI, 2.3-18.9, p = 0.01) for tracheostomy placement on the first and second attempts, respectively. Glasgow Coma Score (GCS), endotracheal tube (ETT) secretion characteristics, and pulmonary variables were not associated with EF or tracheostomy placement.

CONCLUSIONS

A weak/absent cough reflex is associated with an increased risk of failing extubation and placement of a tracheostomy in intubated pediatric NCC patients.

Childhood nosocomial viral acute respiratory tract infections in teaching hospital Anuradhapura, Sri Lanka

Objectives

We have assessed the risk factors for the occurrence of hospital-acquired (HA) and community-acquired (CA) viral acute respiratory tract infections (ARTIs) in children. Children (1–60 months) who were having ARTI on admission (CA) and develops ARTI following 48 h after admission or 3 days of discharge (HA) were included. Indirect immunofluorescence assay (IFA) was performed and multivariable analyses were done to determine the risk factors for the development of viral CA and HA-ARTI.

Results

Total of 818 with ARTIs, 226 (27.6%) RSV cases were detected. Out of 226, 86 (38.0%) HA-RSV cases were detected. CA-viral-ARTI was significantly high (p < 0.05). Compared to CA-RSV-ARTI immunodeficiency, seizures, trisomy-21 and congenital heart disease (CHD) were having 2.3, 3.2, 1.8- and 2.2-times risk for acquiring HA-RSV respectively. The number of deaths was significantly high following HA-RSV. The associated burden was significant following HA-RSV and it was 429.77 disability-adjusted life years. Children who are having immunodeficiency, CHD, seizure episodes and trisomy 21 would lead to the acquisition of nosocomial RSV infections in great. Adherence to meticulous infection control practices will be helpful to minimize the HA-viral ARTIs in great.

Development of an Antibiotic Guideline for Children With Suspected Ventilator-Associated Infections

OBJECTIVES

To develop a guideline for the decision to continue or stop antibiotics at 48-72 hours after their initiation in children with suspected ventilator-associated infection.

DESIGN

Prospective, multicenter observational data collection and subsequent development of an antibiotic guideline.

SETTING

Twenty-two PICUs.

PATIENTS

Children less than 3 years old receiving mechanical ventilation who underwent clinical testing and initiation of antibiotics for suspected ventilator-associated infection.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Phase 1 was a prospective data collection in 281 invasively ventilated children with suspected ventilator-associated infection. The median age was 8 months (interquartile range, 4-16 mo) and 75% had at least one comorbidity. Phase 2 was development of the guideline scoring system by an expert panel employing consensus conferences, literature search, discussions with institutional colleagues, and refinement using phase 1 data. Guideline scores were then applied retrospectively to the phase 1 data. Higher scores correlated with duration of antibiotics (p < 0.001) and higher PEdiatric Logistic Organ Dysfunction 2 scores (p < 0.001) but not mortality, PICU-free days or ventilator-free days. Considering safety and outcomes based on the phase 1 data and aiming for a 25% reduction in antibiotic use, the panel recommended stopping antibiotics at 48-72 hours for guideline scores less than or equal to 2, continuing antibiotics for scores greater than or equal to 6, and offered no recommendation for scores 3, 4, and 5. The acceptability and effect of these recommendations on antibiotic use and outcomes will be prospectively tested in phase 3 of the study.

CONCLUSIONS

We developed a scoring system with recommendations to guide the decision to stop or continue antibiotics at 48-72 hours in children with suspected ventilator-associated infection. The safety and efficacy of the recommendations will be prospectively tested in the planned phase 3 of the study.

Application of the New Centers for Disease Control and Prevention Surveillance Criteria for Ventilator-Associated Events to a Cohort of PICU Patients Identifies Different Patients Compared With the Previous Definition and Physician Diagnosis

OBJECTIVES

We sought to compare the performance of the 2008 Centers for Disease Control and Prevention Pediatric criteria for ventilator-associated pneumonia, the 2013 Adult Ventilator-Associated Condition criteria, the new Draft Pediatric Ventilator-Associated Condition criteria, and physician-diagnosed ventilator-associated pneumonia in a cohort of PICU patients.

DESIGN

Secondary analysis of a previously conducted prospective observational study.

SETTING

PICU within a tertiary care children's hospital between April 1, 2010, and April 1, 2011.

PATIENTS

Patients between 31 days and 18 years old, mechanically ventilated via endotracheal tube for more than 72 hours and no limitations of care.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Ventilator-associated pneumonia criteria applied in real time and ventilator-associated condition criteria applied retrospectively. Outcomes assessed between cases and noncases within criteria. Of the 133 eligible participants, 24 (18%) had ventilator-associated pneumonia by 2008 Pediatric criteria and 27 (20%) by physician diagnosis. Sixteen (12%) and 10 (8%) had ventilator-associated condition by 2013 Adult and Draft Pediatric criteria, respectively. We found significant overlap between cases identified with 2008 Pediatric criteria and physician diagnosis (p = 0.549), but comparisons between the other definitions revealed that the newer criteria identify different patients than previous Centers for Disease Control and Prevention ventilator-associated pneumonia criteria and physician diagnosis (p < 0.01). Although 20 participants were diagnosed with ventilator-associated pneumonia by 2008 Pediatric criteria and physician diagnosis, only three participants were identified by all four criteria. Three subjects uniquely identified by the Draft Pediatric criteria were noninfectious in etiology. Cases identified by all criteria except Draft Pediatric had higher ratios of actual ICU length of stay to Pediatric Risk of Mortality III-adjusted expected length of stay compared with noncases.

CONCLUSIONS

The Draft Pediatric criteria identify fewer and different patients than previous ventilator-associated pneumonia criteria or physician diagnosis, potentially missing patients with preventable harms, but also identified patients with potentially preventable noninfectious respiratory deteriorations. Further investigations are required to maximize the identification of patients with preventable harms from mechanical ventilation.

Predictive value of C-reactive protein and the Pediatric Risk of Mortality III Score for occurrence of postoperative ventilator-associated pneumonia in pediatric patients with congenital heart disease

IMPORTANCE

Ventilator-associated pneumonia (VAP) is one of the most common complications after cardiac surgery in children with congenital heart disease (CHD). Early prediction of the incidence of VAP is important for clinical prevention and treatment.

OBJECTIVE

To determine the value of serum C-reactive protein (CRP) levels and the Pediatric Risk of Mortality III (PRISM III) score in predicting the risk of postoperative VAP in pediatric patients with CHD.

METHODS

We performed a retrospective review of clinical data of 481 pediatric patients with CHD who were admitted to our pediatric intensive care unit. These patients received mechanical ventilation for 48 hours or longer after corrective surgery. On the basis of their clinical manifestations and laboratory results, patients were separated into two groups of those with VAP and those without VAP. CRP levels were measured and PRISM III scores were collected within 12 hours of admission to the pediatric intensive care unit. The Pearson correlation coefficient was used to evaluate the association of CRP levels and the PRISM score with the occurrence of postoperative VAP. A linear regression model was constructed to obtain a joint function and receiver operating curves were used to assess the predictive value.

RESULTS

CRP levels and the PRISM III score in the VAP group were significantly higher than those in the non-VAP group (P < 0.05). Receiver operating curves suggested that using CRP + the PRISM III score to predict the incidence of VAP after congenial heart surgery was more accurate than using either of them alone (CRP + the PRISM III score: sensitivity: 53.2%, specificity: 85.7%). When CRP + the PRISM III score was greater than 45.460, patients were more likely to have VAP.

INTERPRETATION

Although using CRP levels plus the PRISM III score to predict the incidence of VAP after congenial heart surgery is more accurate than using either of them alone, its predictive value is still limited.

Hospital-Acquired Infections in Children: A Latin American Tertiary Teaching Hospital 5-Year Experience

Hospital-acquired infections account for high mortality rates and hospital costs. We analyzed pediatric data from a tertiary teaching hospital and found that most of the cases occurred in the intensive care unit and had significant association with invasive devices. Bloodstream infections were the main site of infection, and Gram-negative bacteria were the predominant etiology.

Methods in the design and implementation of the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) clinical trial

Background

Few papers discuss the pragmatics of conducting large, cluster randomized clinical trials. Here we describe the sequential steps taken to develop methods to implement the Randomized Evaluation of Sedation Titration for Respiratory Failure (RESTORE) trial that tested the effect of a nurse-implemented, goal-directed, comfort algorithm on clinical outcomes in pediatric patients with acute respiratory failure.

Methods

After development in a single institution, the RESTORE intervention was pilot-tested in two pediatric intensive care units (PICUs) to evaluate safety and feasibility. After the pilot, the RESTORE intervention was simplified to enhance reproducibility across multiple PICUs. The final RESTORE trial was developed as a cluster randomized clinical trial where the unit of randomization was the PICU, stratified by PICU size, and the unit of inference was the patient. Study execution was revised based on our Data and Safety Monitoring Board’s recommendation to consult with the Department of Health and Human Services’ Office of Human Research Protection (OHRP) on how best to consent eligible subjects. OHRP deemed that the RESTORE intervention posed greater than minimal risk and that all enrolled subjects provide consent reflecting their level of participation.

Results

Thirty-one PICUs of varying size, organization and academic affiliation participated and over 2800 critically ill infants and children supported on mechanical ventilation for acute pulmonary disease were enrolled. The primary outcome for the trial was the duration of mechanical ventilation; secondary outcomes included time awake and comfortable, total sedative exposure and iatrogenic withdrawal symptoms. Throughout the clinical trial the investigative team worked to maintain treatment fidelity, enrollment milestones and co-investigator enthusiasm. We considered the potential impact of competing clinical trials through a decision-making framework.

Conclusions

The RESTORE clinical trial was a large and complex multicenter study that has provided the necessary evidence to guide sedation practices in the field of pediatric critical care. Specific issues that were unique to this trial included level of consent, adding clinical sites to augment enrollment and evaluating the potential impact of competing clinical trials.

Trial registration

ClinicalTrials.gov, Identifiers: Pilot trial: NCT00142766; Retrospectively registerd on 2 September 2005.

Cluster randomized trial: NCT00814099. Registered on 23 December 2008.

Ventilator Associated Pneumonia in Pediatric Intensive Care Unit: Incidence, Risk Factors and Etiological Agents

OBJECTIVES

To study the incidence, etiology and risk factors associated with ventilator associated pneumonia (VAP) in children.

METHODS

This prospective cohort study was conducted on patients admitted to the Pediatric Intensive Care Unit (PICU) of a tertiary care institute of North India, from June 2012 through March 2014, who received mechanical ventilation for more than 24 h. All enrolled children were assessed daily for development of ventilator associated pneumonia (VAP) using the case definition given by Centers for Disease Control and Prevention (CDC). Chest radiograph and microbiologic samplings were performed in children suspected to have VAP. Risk factors associated with VAP were calculated by doing bivariate and multivariate analysis.

RESULTS

A total of 128 patients were screened and 86 were enrolled (median age 30 mo 95% CI 4.0-84.0; 72% boys). The most common admitting diagnosis was sepsis (16%) followed by acyanotic congenital heart disease with pneumonia (14%) and the most common indication for ventilation was respiratory failure (45.3%). The incidence of VAP according to CDC criteria was 38.4%, while the incidence of microbiologically confirmed VAP was 24.4%. The incidence of ventilator associated tracheobronchitis (VAT) was found to be 11.6%. Acinetobacter was the most frequently isolated organism (47%) followed by Pseudomonas (28%), Klebsiella (15%), E. coli (5%) and Enterobacter (5%). Risk factors for VAP on bivariate analysis were use of proton pump inhibitor (PPI) (p = 0.027, OR 5.2, 95% CI 1.1-24.3), enteral feeding (p < 0.001, OR 6.5, 95% CI 2.1-19.4) and re-intubation (p = 0.024, OR 3.3 and 95% CI 1.1-9.6). On multivariate analysis, use of PPI (p = 0.03, OR 8.47, 95% CI 1.19-60.33) and enteral feeding (p < 0.001, OR 12.2, 95% CI 2.58-57.78) were identified as independent risk factors for VAP.

CONCLUSIONS

Ventilator associated pneumonia is an important complication in children receiving mechanical ventilation in PICU and Gram negative bacilli (Acinetobacter and Pseudomonas) being the important causative agents. Ventilator associated tracheobronchitis is an emerging entity; recognition and treatment of same might prevent the development of VAP.

Retrospective Application of New Pediatric Ventilator-Associated Pneumonia Criteria Identifies a High-Risk Population

OBJECTIVES

To promote standardization, the Centers for Disease Control and Prevention introduced a new ventilator-associated pneumonia classification, which was modified for pediatrics (pediatric ventilator-associated pneumonia according to proposed criteria [PVAP]). We evaluated the frequency of PVAP in a cohort of children diagnosed with ventilator-associated pneumonia according to traditional criteria and compared their strength of association with clinically relevant outcomes.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care pediatric hospital.

PATIENTS

Critically ill children (0-18 yr) diagnosed with ventilator-associated pneumonia between January 2006 and December 2015 were identified from an infection control database. Patients were excluded if on high frequency ventilation, extracorporeal membrane oxygenation, or reintubated 24 hours following extubation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were assessed for PVAP diagnosis. Primary outcome was the proportion of subjects diagnosed with PVAP. Secondary outcomes included association with intervals of care. Two hundred seventy-seven children who had been diagnosed with ventilator-associated pneumonia were eligible for review; 46 were excluded for being ventilated under 48 hours (n = 16), on high frequency ventilation (n = 12), on extracorporeal membrane oxygenation (n = 8), ineligible bacteria isolated from culture (n = 8), and other causes (n = 4). ICU admission diagnoses included congenital heart disease (47%), neurological (16%), trauma (7%), respiratory (7%), posttransplant (4%), neuromuscular (3%), and cardiomyopathy (3%). Only 16% of subjects (n = 45) met the new PVAP definition, with 18% (n = 49) having any ventilator-associated condition. Failure to fulfill new definitions was based on inadequate increase in mean airway pressure in 90% or FIO2 in 92%. PVAP was associated with prolonged ventilation (median [interquartile range], 29 d [13-51 d] vs 16 d [8-34.5 d]; p = 0.002), ICU (median [interquartile range], 40 d [20-100 d] vs 25 d [14-61 d]; p = 0.004) and hospital length of stay (median [interquartile range], 81 d [40-182 d] vs 54 d [31-108 d]; p = 0.04), and death (33% vs 16%; p = 0.008).

CONCLUSIONS

Few children with ventilator-associated pneumonia diagnosis met the proposed PVAP criteria. PVAP was associated with increased morbidity and mortality. This work suggests that additional study is required before new definitions for ventilator-associated pneumonia are introduced for children.

New Biomarkers to Diagnose Ventilator Associated Pneumonia: Pentraxin 3 and Surfactant Protein D

OBJECTIVE

To detect the most effective biomarker to confirm ventilator associated pneumonia (VAP).

METHODS

Fifty patients with VAP suspicious diagnosis and 30 healthy patients were recruited. Suspicion of VAP was established if patients met the modified CPIS score ≥ 6 points. The confirmation of VAP was defined by the quantitative culture of nonbronchoscopic bronchoalveolar lavage (BAL) >10⁵ CFU/ml of pathogenic microorganism. Serum samples for determination of C-reactive protein (CRP), procalcitonin (PCT), pentraxin 3 (PTX3), surfactant protein D (SPD) were collected on suspected VAP.

RESULTS

Twenty seven of 50 patients were accepted as confirmed VAP group whose nonbronchoscopic BAL cultures were positive and rest of them were accepted as unconfirmed VAP group. PTX3, PCT and SPD levels were significantly higher in confirmed VAP group, (P = 0.021, P = 0.007, P < 0.001 respectively). There were no significant differences in CRP levels between the two groups (P = 0.062). The most sensitive marker for diagnosing VAP was SPD (P < 0.001). Receiver operating characteristic (ROC) curve for modified clinical pulmonary infection score (CPIS) to confirm VAP was evaluated (AUC 0.741 ± 0.07, P < 0.001) and the optimal cutoff value was >7 with a sensitivity of 51.85% and a specificity of 91.3%. SPD levels were significantly higher in Acinetobacter baumannii and Pseudomonas aeruginosa infected patients than culture negative patients (P < 0.001).

CONCLUSIONS

The index findings suggest that serum SPD is the most sensitive biomarker in diagnosis of VAP and it can be used as an early and organism specific marker for Acinetobacter baumannii and Pseudomonas aeruginosa.

Presence of Invasive Devices and Risks of Healthcare-Associated Infections and Sepsis

The present study evaluated the daily risk of healthcare-associated infections and sepsis (HAIS) events in pediatric intensive care unit patients with invasive devices. This was a retrospective cohort study. Invasive devices were associated with significant daily risk of HAIS ( p  < 0.05). Endotracheal tubes posed the greatest risk of HAIS (hazard ratio [HR]: 4.39, confidence interval [CI]: 2.59-7.46). Children with both a central venous catheter (CVC) and urinary catheter (UC) had over 2.5-fold increased daily risk (HR: 2.59, CI: 1.18-5.68), in addition to daily CVC risk (HR: 3.06, CI: 1.38-6.77) and daily UC risk (HR: 8.9, CI: 3.62-21.91). We conclude that a multistate hazard model optimally predicts daily HAIS risk.

Future Directions and Molecular Basis of Ventilator Associated Pneumonia

Mechanical ventilation is a lifesaving treatment and has complications such as ventilator associated pneumonia (VAP) that lead to high morbidity and mortality. Moreover VAP is the second most common hospital-acquired infection in pediatric intensive care units. Although it is still not well understood, understanding molecular pathogenesis is essential for preventing and treating pneumonia. A lot of microbes are detected as a causative agent of VAP. The most common isolated VAP pathogens in pediatric patients are Staphylococcus aureus, Pseudomonas aeruginosa, and other gram negative bacteria. All of the bacteria have different pathogenesis due to their different virulence factors and host reactions. This review article focused on mechanisms of VAP with molecular pathogenesis of the causative bacteria one by one from the literature. We hope that we know more about molecular pathogenesis of VAP and we can investigate and focus on the management of the disease in near future.

Postural lung recruitment assessed by lung ultrasound in mechanically ventilated children

Background

Atelectasis is a common finding in mechanically ventilated children with healthy lungs. This lung collapse cannot be overcome using standard levels of positive end-expiratory pressure (PEEP) and thus for only individualized lung recruitment maneuvers lead to satisfactory therapeutic results. In this short communication, we demonstrate by lung ultrasound images (LUS) the effect of a postural recruitment maneuver (P-RM, i.e., a ventilatory strategy aimed at reaerating atelectasis by changing body position under constant ventilation).

Results

Data was collected in the operating room of the Hospital Privado de Comunidad, Mar del Plata, Argentina. Three anesthetized children undergoing mechanical ventilation at constant settings were sequentially subjected to the following two maneuvers: (1) PEEP trial in the supine position PEEP was increased to 10 cmH₂O for 3 min and then decreased to back to baseline. (2) P-RM patient position was changed from supine to the left and then to the right lateral position for 90 s each before returning to supine. The total P-RM procedure took approximately 3 min. LUS in the supine position showed similar atelectasis before and after the PEEP trial. Contrarily, atelectasis disappeared in the non-dependent lung when patients were placed in the lateral positions. Both lungs remained atelectasis free even after returning to the supine position.

Conclusions

We provide LUS images that illustrate the concept and effects of postural recruitment in children. This maneuver has the advantage of achieving recruitment effects without the need to elevate airways pressures.

Electronic supplementary material

The online version of this article (doi:10.1186/s13089-017-0073-0) contains supplementary material, which is available to authorized users.

Ventilator-Associated Pneumonia in Critically Ill Children: A New Paradigm

Ventilator-associated pneumonia (VAP) is a serious complication of critical illness. Surveillance definitions have undergone revisions for more objective and consistent reporting. The 1 organism-1 disease paradigm for microbial involvement may not adequately apply to many cases of VAP, in which pathogens are introduced to a pre-existing and often complex microbial community that facilitates or hinders the potential pathogen, consequently determining whether progression to VAP occurs. As omics technology is applied to VAP, a paradigm is emerging incorporating simultaneous assessments of microbial populations and their activity, as well as the host response, to personalize prevention and treatment.

Creating a Highly Reliable Neonatal Intensive Care Unit Through Safer Systems of Care

Neonates requiring intensive care are at high risk for medical errors due to their unique characteristics and high acuity. Designing a safer work environment begins with safe processes. Creating a culture of safety demands the involvement of all organizational levels and an interdisciplinary approach. Adverse events can result from suboptimal communication and lack of a shared mental model. This chapter describes tools to promote better patient safety in the NICU through monitoring adverse events, improving communication and using information technology. Unplanned extubation is an example of a neonatal safety concern that can be reduced by employing quality improvement methodology.

Mechanical ventilation practice in Egyptian pediatric intensive care units

Introduction

Mechanical ventilation is one of the indispensable tools in pediatric intensive care units. Few studies addressed the epidemiology of pediatric patients on mechanical ventilation and the frequently used modes of ventilation. This is the first study to describe the practice of mechanical ventilation (MV) in Egyptian pediatric intensive care units (PICUs).

Methods

This prospective observational study was conducted from January 2014 to December 2014 in two pediatric intensive care units at Cairo University Pediatric Hospital. The study included all children who were intubated and mechanically ventilated for more than 12 hours of admission. Pre-coded data was entered into the SPSS version 21 for data analysis. Comparison between groups was performed using Mann Whitney test for quantitative variables and Chi square with Fisher’s exact test for qualitative ones. Multivariate logistic regression model was conducted to explore the significant predictors for PICU mortality.

Results

In total, 893 children were admitted and 293 were mechanically ventilated. The incidence of utilizing MV in children was 32.8%. Neurologic causes were the most common reasons for initiation of MV, with 114 (38.9%) cases. The most commonly preferred mode for initiation of MV is SIMV with PS. Complication occurred in 117 (39.9%) of the cases. The most commonly preferred method of weaning was PS with CPAP in 115/154 (74.7%) cases. Mortality occurred in 134/293 (45.7%) of patients. Duration of mechanical ventilation was significantly longer with neuromuscular diseases, and with the occurrence of complications (p<0.001). There was a significant relationship between mortality and higher PRISM III score, cardiovascular cases, sepsis, multiple organ dysfunction syndrome (MODS), ventilator-associated pneumonia (VAP), and with barotrauma.

Conclusions

In our practice, MV is used oftentimes with almost a third of admissions requiring intubation for different reasons. Most children are ventilated due to neurologic causes. This study paves the way for improving our knowledge of MV with avoiding the fatal complications.