In ICU-resuscitated patients, targeting only ScvO(2) may not be sufficient to guide therapy. When the 70% ScvO(2) goal-value is reached, the presence of a P(cv-a)CO(2) larger than 6 mmHg might be a useful tool to identify patients who still remain inadequately resuscitated.

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Objective:We hypothesize that the major consciousness deficit observed in coma is due to the breakdown of long-range neuronal communication supported by precuneus and posterior cingulate cortex (PCC), and that prognosis depends on a specific connectivity pattern in these networks.Methods:We compared 27 prospectively recruited comatose patients who had severe brain injury (Glasgow Coma Scale score <8; 14 traumatic and 13 anoxic cases) with 14 age-matched healthy participants. Standardized clinical assessment and fMRI were performed on average 4 ± 2 days after withdrawal of sedation. Analysis of resting-state fMRI connectivity involved a hypothesis-driven, region of interest–based strategy. We assessed patient outcome after 3 months using the Coma Recovery Scale–Revised (CRS-R).Results:Patients who were comatose showed a significant disruption of functional connectivity of brain areas spontaneously synchronized with PCC, globally notwithstanding etiology. The functional connectivity strength between PCC and medial prefrontal cortex (mPFC) was significantly different between comatose patients who went on to recover and those who eventually scored an unfavorable outcome 3 months after brain injury (Kruskal-Wallis test, p < 0.001; linear regression between CRS-R and PCC-mPFC activity coupling at rest, Spearman ρ = 0.93, p < 0.003).Conclusion:In both etiology groups (traumatic and anoxic), changes in the connectivity of PCC-centered, spontaneously synchronized, large-scale networks account for the loss of external and internal self-centered awareness observed during coma. Sparing of functional connectivity between PCC and mPFC may predict patient outcome, and further studies are needed to substantiate this potential prognosis biomarker.

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This study demonstrated for the first time to our knowledge a significantly better performance of TUS than LUS in the diagnosis of ARF. The value of the TUS approach was particularly important to disambiguate cases of hemodynamic pulmonary edema and pneumonia. We suggest that the bedside use of artificial intelligence methods in this setting could pave the way for the development of new clinically relevant integrative diagnostic models.

IntroductionEchocardiographic indices based on respiratory variations of superior and inferior vena cavae diameters (ΔSVC and ΔIVC, respectively) have been proposed as predictors of fluid responsiveness in mechanically ventilated patients, but they have never been compared simultaneously in the same patient sample. The aim of this study was to compare the predictive value of these echocardiographic indices when concomitantly recorded in mechanically ventilated septic patients.MethodsSeptic shock patients requiring hemodynamic monitoring were prospectively enrolled over a 1-year period in a mixed medical surgical ICU of a university teaching hospital (Toulouse, France). All patients were mechanically ventilated. Predictive indices were obtained by transesophageal and transthoracic echocardiography and were calculated as follows: (Dmax − Dmin)/Dmax for ΔSVC and (Dmax − Dmin)/Dmin for ΔIVC, where Dmax and Dmin are the maximal and minimal diameters of SVC and IVC. Measurements were performed at baseline and after a 7-ml/kg volume expansion using a plasma expander. Patients were separated into responders (increase in cardiac index ≥15%) and nonresponders (increase in cardiac index <15%).ResultsAmong 44 included patients, 26 (59%) patients were responders (R). ΔSVC was significantly more accurate than ΔIVC in predicting fluid responsiveness. The areas under the receiver operating characteristic curves for ΔSVC and ΔIVC regarding assessment of fluid responsiveness were significantly different (0.74 (95% confidence interval (CI): 0.59 to 0.88) and 0.43 (95% CI: 0.25 to 0.61), respectively (P = 0.012)). No significant correlation between ΔSVC and ΔIVC was found (r = 0.005, P = 0.98). The best threshold values for discriminating R from NR was 29% for ΔSVC, with 54% sensitivity and 89% specificity, and 21% for ΔIVC, with 38% sensitivity and 61% specificity.ConclusionsΔSVC was better than ΔIVC in predicting fluid responsiveness in our cohort. It is worth noting that the sensitivity and specificity values of ΔSVC and ΔIVC for predicting fluid responsiveness were lower than those reported in the literature, highlighting the limits of using these indices in a heterogeneous sample of medical and surgical septic patients.

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