Fetal exposure to the maternal microbiota in humans and mice.

Previous studies have demonstrated the presence of microbial DNA in the fetal environment. However, it remains unclear whether this DNA represents viable bacteria and how it relates to the maternal microbiota across body sites. We studied the microbiota of human and mouse dyads to understand these relationships, localize bacteria in the fetus, and demonstrate bacterial viability. In human preterm and full-term mother-infant dyads at the time of cesarean delivery, the oral cavity and meconium of newborn infants born as early as 24 weeks of gestation contained a microbiota that was predicted to originate from in utero sources, including the placenta. Using operative deliveries of pregnant mice under highly controlled, sterile conditions in the laboratory, composition, visualization, and viability of bacteria in the in utero compartment and fetal intestine were demonstrated by 16S rRNA gene sequencing, fluorescence in situ hybridization, and bacterial culture. The composition and predicted source of the fetal gut microbiota shifted between mid- and late gestation. Cultivatable bacteria in the fetal intestine were found during mid-gestation but not late gestation. Our results demonstrate a dynamic, viable mammalian fetal microbiota during in utero development.

Impact of disease-specific orientation on new graduate nurse satisfaction and knowledge retention.

Transition from student to novice nurse can be especially challenging, and a weak orientation can further complicate this difficult time for new graduate nurses. The neuroscience field is complex, and orientation can cause new nurses to lack a comprehensive understanding of their specialty, resulting in a task-focused approach to bedside care. Using a convenience sample and both qualitative and quantitative data, this study implements a disease-specific orientation track for new graduate nurses to spotlight the most common neurological diagnoses and disorders while concentrating on building an understanding of how to provide the best care possible to these patients. This article reports the outcomes achieved from the first phase of the study including improved clinical competence, readiness and retention of knowledge, overall satisfaction with orientation, and increased comfort level in caring for the neurological patient. In addition, the feedback and information gathered have provided a foundation for the project to be tailored and continued to further improve these results with future new graduate nurses on the neuroscience unit.

Albuterol delivery from a metered-dose inhaler with spacer is reduced following short-duration manual ventilation in a neonatal ventilator-lung model.

INTRODUCTION: Albuterol aerosol is commonly administered to mechanically ventilated neonates via metered-dose inhaler (MDI) with spacer. The spacer increases the dead space in the ventilation circuit, and some institutions limit the amount of time the spacer remains in line, to minimize carbon dioxide retention and the risk of hypercarbia. However, minimizing the amount of time the spacer remains in line might also limit albuterol delivery to the patient. OBJECTIVE: To determine whether limiting the amount of time the spacer is left in line after MDI actuation significantly reduces albuterol delivery. METHODS: We conducted a bench study with a neonatal ventilator-lung model that included a Bird VIP ventilator, in a time-cycled, pressure-limited, continuous-flow mode, with settings to simulate a 1-kg infant with moderate lung disease: peak inspiratory pressure 25 cm H2O, positive end-expiratory pressure 4 cm H2O, respiratory rate 30 breaths/min, inspiratory time 0.35 s, tidal volume approximately 7 mL. The circuit was attached to a 3.0-mm inner-diameter endotracheal tube and a neonatal test lung. We tested 5 methods of MDI albuterol administration. The first 3 methods used a spacer attached to the ETT and either 5, 15, or 30 manual breaths (flow 6 L/min, respiratory rate 30 breaths/min, peak inspiratory pressure 25 cm H2O) were delivered after each MDI actuation (2 actuations). The final 2 methods used an in-line spacer (placed between the circuit Y-piece and the endotracheal tube) with the spacer kept in line for 30 or 60 s after each actuation (2 actuations). A breathing filter was placed between the ETT and test lung to trap the aerosolized albuterol. RESULTS: Mean +/- SD albuterol delivery was 2.3 +/- 0.5%, 3.6 +/- 1.8%, and 5.1 +/- 1.3% after 5, 15, and 30 manual breaths, respectively (p < or = 0.05 for 30 breaths vs 5 and 15 breaths). Albuterol delivery was 3.7 +/- 1.3% when the spacer was left in line for 30 s, versus 3.7 +/- 0.6% when it was left in line for 60 s. CONCLUSIONS: Limiting the time that the spacer was left in line after each MDI actuation significantly reduced albuterol delivery in our neonatal ventilator-lung model.

A survey of albuterol administration practices in intubated patients in the neonatal intensive care unit.

INTRODUCTION: Aerosolized albuterol is commonly used in the treatment of neonatal respiratory illnesses. Clinical and in vitro studies have identified numerous factors that affect aerosol drug delivery during neonatal mechanical ventilation, including the choice of metered-dose inhaler (MDI) or nebulizer, the use of a holding chamber, time between actuations, the volume of nebulized solution, and the position and placement of the nebulizer or MDI. Because there is no consensus on the optimal method of administration, there is probably substantial variability among institutions in how aerosolized albuterol is administered to mechanically ventilated infants in the neonatal intensive care unit (NICU). OBJECTIVE: Survey academic medical centers in the United States regarding their practices of administering aerosolized albuterol to intubated newborns in the NICU. METHODS: A survey instrument was developed that queried 18 aspects of albuterol administration in mechanically ventilated infants, including the frequency of MDI and nebulizer use, the average and maximum dose, the time between MDI actuations and following the final actuation, the use of a holding chamber, and the placement location of the holding chamber or nebulizer. Respiratory therapists and respiratory therapy managers having direct knowledge of neonatal clinical practices in their neonatal fellowship program NICUs were surveyed via telephone. Those who did not respond via telephone were surveyed via fax. RESULTS: Eighty institutions were surveyed and there were 68 respondents (85% response rate). Responders averaged 35 +/- 13 NICU beds and 11 +/- 5 ventilators/d. Nineteen percent of the respondents reported administering albuterol via MDI 100% of the time; 22% use MDIs 75-99% of the time; 9% use MDIs 50-74% of the time; 4% use MDIs 25-49% of the time; and 43% never use MDIs to deliver albuterol. The average dose via MDI was: 1 puff: 30%; 2 puffs: 65%; and 4 puffs: 5%. The maximum dose via MDI was: 2 puffs: 30%; 3 puffs: 14%; 4 puffs: 36%; 6 puffs: 11%; and 8 puffs: 6%. Thirty-one percent of the respondents place the holding chamber in-line with the ventilator circuit, 56% administer the aerosol via manual ventilation, and 13% use both methods. Fifty-six percent place the in-line holding chamber between the endotracheal tube and ventilator circuit, and the other 44% place the in-line holding chamber in the inspiratory limb. The time between MDI actuations depended on whether the holding chamber was placed in-line or the aerosol was administered via manual ventilation (MV): < or = 0.5 min: 18% in-line and 28% MV; 1 min: 47% in-line and 43% MV; 2 min: 6% in-line and 4% MV; 3 min: 6% in-line and 0% MV. Eighty-three percent of respondents indicated that dead space introduced by a holding chamber/spacer was not a concern. Forty-three percent use nebulizers exclusively to administer albuterol to mechanically ventilated patients. Seventy-four percent of centers that nebulize albuterol use a dose of 1.25-2.5 mg. Eighty-eight percent of the surveyed institutions place nebulizers in-line with the ventilator circuit, and the other 12% use manual ventilation to administer the nebulized aerosol. Of those that use in-line nebulization, 95% place the nebulizer in the inspiratory limb of the circuit, and the other 5% place the nebulizer between the endotracheal tube and circuit Y-piece. Among centers that place the nebulizer in the inspiratory limb, 52% place it adjacent to the circuit Y-piece, 36% place it midway upstream in the inspiratory limb, and 12% place it near the humidifier. CONCLUSION: There is substantial variability among NICUs in albuterol administration to mechanically ventilated infants, with the majority of institutions now administering albuterol via MDI.