Dilip Jayasimhan
@dilipj1.bsky.social
Respiratory physician and intensive care fellow 🇲🇾 🇳🇿
Reposted by Dilip Jayasimhan
Insulin gtt + usual management. Oral triglyceride meds going forward.
July 10, 2025 at 8:34 PM
Insulin gtt + usual management. Oral triglyceride meds going forward.
A lot of times, just good simple intensive care goes a long way.
July 11, 2025 at 10:19 AM
A lot of times, just good simple intensive care goes a long way.
What does be careful mean, though?
June 14, 2025 at 2:23 AM
What does be careful mean, though?
Using PSV pretty early and primarily as a ventilatory mode (not for SBT) would be usual practice in most centers in Australia & New Zealand.
June 14, 2025 at 12:41 AM
Using PSV pretty early and primarily as a ventilatory mode (not for SBT) would be usual practice in most centers in Australia & New Zealand.
Reposted by Dilip Jayasimhan
Nice thread. Well summarised. Thank you. Imho- prone ventilation helps homogenise distribution of mechanical power. If on VV and on “rest” ventilation (whatever that is since no consensus on what rest is whilst ELSo guidelines allude to) then the benefit from proning is v minimal
June 9, 2025 at 2:01 PM
Nice thread. Well summarised. Thank you. Imho- prone ventilation helps homogenise distribution of mechanical power. If on VV and on “rest” ventilation (whatever that is since no consensus on what rest is whilst ELSo guidelines allude to) then the benefit from proning is v minimal
PRONECMO used a competing risk analysis as the outcome, and hence, I do not understand the power calculations. If someone could explain this to me, I'd be grateful. From my perspective, however, I wonder if a trial with 170 patients is definitive on the effect of PP in ECMO.
June 9, 2025 at 9:28 AM
PRONECMO used a competing risk analysis as the outcome, and hence, I do not understand the power calculations. If someone could explain this to me, I'd be grateful. From my perspective, however, I wonder if a trial with 170 patients is definitive on the effect of PP in ECMO.
A simple sample size calculation shows that to reduce mortality from 35% to 20%, you'd need to enrol 276 patients, which still amounts to a lot of patients on ECMO. Reduce that estimate of effect to 10%, and you'd need to recruit 878 patients.
June 9, 2025 at 9:28 AM
A simple sample size calculation shows that to reduce mortality from 35% to 20%, you'd need to enrol 276 patients, which still amounts to a lot of patients on ECMO. Reduce that estimate of effect to 10%, and you'd need to recruit 878 patients.
EOLIA had a 60-day mortality of 35% in the ECMO group. It's unlikely, I believe, that PP would reduce mortality by 15% in this group, let alone at the levels observed in PROSEVA, given that ECMO allows a safe reduction in driving pressure, one of the benefits of PP.
June 9, 2025 at 9:28 AM
EOLIA had a 60-day mortality of 35% in the ECMO group. It's unlikely, I believe, that PP would reduce mortality by 15% in this group, let alone at the levels observed in PROSEVA, given that ECMO allows a safe reduction in driving pressure, one of the benefits of PP.
Power calculations for PROSEVA estimated a 28d mortality of 60% in the control group and required enrolling 456 patients for 90% power to detect a 15% absolute reduction in mortality. The mortality in the control group was higher at 75%, with PP mortality of 38%. The true effect is likely smaller.
June 9, 2025 at 9:28 AM
Power calculations for PROSEVA estimated a 28d mortality of 60% in the control group and required enrolling 456 patients for 90% power to detect a 15% absolute reduction in mortality. The mortality in the control group was higher at 75%, with PP mortality of 38%. The true effect is likely smaller.
Mostly by titrating PEEP and prone positioning. Occasionally using a brief recruitment maneuver as rescue.
June 6, 2025 at 10:40 PM
Mostly by titrating PEEP and prone positioning. Occasionally using a brief recruitment maneuver as rescue.
As important as understanding the physiological rationale of APRV and its potential efficacy is, it is equally crucial to assess how well-prepared your system is to adopt and apply a new approach to demonstrate effectiveness. This partly explains the difficulties in performing large APRV RCTs.
June 6, 2025 at 1:28 AM
As important as understanding the physiological rationale of APRV and its potential efficacy is, it is equally crucial to assess how well-prepared your system is to adopt and apply a new approach to demonstrate effectiveness. This partly explains the difficulties in performing large APRV RCTs.
There may be individuals within the system who are comfortable and able to use this mode, but it would be worthless if the system as a whole (the rest of the team) is not. Unfamiliar strategies introduce complexity, and increasing complexity may lead to increased noise in decision-making.
June 6, 2025 at 1:28 AM
There may be individuals within the system who are comfortable and able to use this mode, but it would be worthless if the system as a whole (the rest of the team) is not. Unfamiliar strategies introduce complexity, and increasing complexity may lead to increased noise in decision-making.
I work in a system or region of systems where APRV is very rarely used, ventilator alterations are minimal, and typically undertaken by doctors and nurses (with no respiratory therapists, etc.).
June 6, 2025 at 1:28 AM
I work in a system or region of systems where APRV is very rarely used, ventilator alterations are minimal, and typically undertaken by doctors and nurses (with no respiratory therapists, etc.).
Although this is biologically plausible, at present, the certainty of the evidence is low. However, more trials will be conducted evaluating this question in the coming years. journal.chestnet.org/article/S001...
Prophylactic Antibiotics in Adults With Acute Brain Injury Who Are Invasively Ventilated in the ICU
Current evidence from randomized clinical trials does not provide definitive evidence
regarding the effect of prophylactic antibiotics on mortality in patients receiving
invasive mechanical ventilatio...
journal.chestnet.org
May 27, 2025 at 7:08 PM
Although this is biologically plausible, at present, the certainty of the evidence is low. However, more trials will be conducted evaluating this question in the coming years. journal.chestnet.org/article/S001...
Other disciplines have shown the benefits of identifying disease behaviours. An example is the idea of a progressive fibrotic phenotype in ILD, which now has therapies that have shown benefit despite the underlying entities being heterogeneous (IPF, Fibrotic HP, NSIP, etc.).
May 27, 2025 at 7:14 AM
Other disciplines have shown the benefits of identifying disease behaviours. An example is the idea of a progressive fibrotic phenotype in ILD, which now has therapies that have shown benefit despite the underlying entities being heterogeneous (IPF, Fibrotic HP, NSIP, etc.).
I agree that clustering patients into syndromes has its limitations. The current clusters are nowhere near perfect. However, I disagree that this is not worth studying. Many patients with different etiologies of critical illness share common pathways that may benefit from a particular treatment.
May 27, 2025 at 7:13 AM
I agree that clustering patients into syndromes has its limitations. The current clusters are nowhere near perfect. However, I disagree that this is not worth studying. Many patients with different etiologies of critical illness share common pathways that may benefit from a particular treatment.
I struggled to find any. I suspect a big cost to running such a trial (without industry sponsorship) is the equipment and resources.
May 27, 2025 at 12:28 AM
I struggled to find any. I suspect a big cost to running such a trial (without industry sponsorship) is the equipment and resources.
That's a fair point. I was just picking a trial to illustrate that these therapies can be evaluated systematically rather than specifically endorsing that particular trial.
May 26, 2025 at 10:31 PM
That's a fair point. I was just picking a trial to illustrate that these therapies can be evaluated systematically rather than specifically endorsing that particular trial.
Reposted by Dilip Jayasimhan
I rather think it’s action bias, easier to do something than to wait and see. People overestimate the risk of deterioration and underestimate bleeding risk.
May 26, 2025 at 5:19 AM
I rather think it’s action bias, easier to do something than to wait and see. People overestimate the risk of deterioration and underestimate bleeding risk.
I guess the question is how much we value shortening the illness over the small but catastrophic risk of a major bleed.
May 25, 2025 at 9:12 PM
I guess the question is how much we value shortening the illness over the small but catastrophic risk of a major bleed.