Reposted by Dilip JayasimhanInternational Society for Heart and Lung Transplantation (ISHLT) @ishlt.bsky.social · 30/03/2026This month's #ISHLTJournalWatch features studies in critical care and transplant anesthesiology. Brigitte Hollander of Auckland City Hospital is the guest editor for the issue. #medsky #pulmsky #transplantsky www.ishlt.org/about/news-d...ishlt.orgAnesthesiology and Critical Care Transplant Topics on Journal WatchPresented by the ISHLT Early Career and Trainee Committee, this month's ISHLT Journal Watch explores topics in critical care and transplant-related topics in anesthesiology. 221
Dilip Jayasimhan @dilipj1.bsky.social · 27/03/2026But these results are heavily weighted by a prior that is based on a subgroup analysis from the EUPHRATES trial. When using an uninformative prior, the results appear to be very unconvincing. 040
Dilip Jayasimhan @dilipj1.bsky.social · 13/08/2025On the note of VAP, we've written a review article. More specifically, focusing on the evidence behind strategies to prevent and manage VAP. This link gives 50 days of free access. Hope you all find it useful. #emimcc authors.elsevier.com/a/1lbEr7K3e2...authors.elsevier.com 141
Reposted by Dilip JayasimhanEmily Fridenmaker @emilyfri.bsky.social · 10/07/2025Insulin gtt + usual management. Oral triglyceride meds going forward. 241
Dilip Jayasimhan @dilipj1.bsky.social · 11/07/2025A lot of times, just good simple intensive care goes a long way. 020
Dilip Jayasimhan @dilipj1.bsky.social · 14/06/2025Using PSV pretty early and primarily as a ventilatory mode (not for SBT) would be usual practice in most centers in Australia & New Zealand. 020
Reposted by Dilip JayasimhanTeddy Tun Win HLA @teddyhla.bsky.social · 09/06/2025Nice 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 111
Dilip Jayasimhan @dilipj1.bsky.social · 09/06/2025PRONECMO 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. 120
Dilip Jayasimhan @dilipj1.bsky.social · 09/06/2025A 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. 120
Dilip Jayasimhan @dilipj1.bsky.social · 09/06/2025EOLIA 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. 110
Dilip Jayasimhan @dilipj1.bsky.social · 09/06/2025Power 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. 110
Dilip Jayasimhan @dilipj1.bsky.social · 09/06/2025I think, given that it took many trials with different sample sizes and durations of proning for us to realise its effectiveness in ARDS without ECMO, it would be even harder to prove in patients on ECMO for several reasons. COI: I love to prone 🧵 #emimcc 160
Dilip Jayasimhan @dilipj1.bsky.social · 06/06/2025Mostly by titrating PEEP and prone positioning. Occasionally using a brief recruitment maneuver as rescue. 020
Dilip Jayasimhan @dilipj1.bsky.social · 06/06/2025As 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. 120
Dilip Jayasimhan @dilipj1.bsky.social · 06/06/2025There 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. 120
Dilip Jayasimhan @dilipj1.bsky.social · 06/06/2025I 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.). 110
Dilip Jayasimhan @dilipj1.bsky.social · 06/06/2025I don't have strong opinions about APRV, but I think the utility and effectiveness of certain strategies depend heavily on the system within which they work. #EMIMCC 171
Dilip Jayasimhan @dilipj1.bsky.social · 04/06/2025A well written argument cautioning against misinterpreting evidence from clinical trials on angiotensin II. Currently, A-II is not available outside a clinical trial where I work. However, there are efforts to evaluate A-II in other populations (not sepsis). pmc.ncbi.nlm.nih.gov/articles/PMC...pmc.ncbi.nlm.nih.govA Prospective double-blind, randomised controlled trial comparing angiotensin II to norepinephrine to reduce length of hospital stay in cardiac surgery patients (the PORTHOS study protocol)Cardiac surgery is frequently associated with vasoplegia and vasopressor treatment. Both may be associated with postoperative complications and prolonged length of stay. The most frequently used vasop... 170
Dilip Jayasimhan @dilipj1.bsky.social · 27/05/2025Although 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...journal.chestnet.orgProphylactic Antibiotics in Adults With Acute Brain Injury Who Are Invasively Ventilated in the ICUCurrent evidence from randomized clinical trials does not provide definitive evidence regarding the effect of prophylactic antibiotics on mortality in patients receiving invasive mechanical ventilatio... 110
Dilip Jayasimhan @dilipj1.bsky.social · 27/05/2025Other 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.). 110
Dilip Jayasimhan @dilipj1.bsky.social · 27/05/2025I 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. 110
Dilip Jayasimhan @dilipj1.bsky.social · 27/05/2025I struggled to find any. I suspect a big cost to running such a trial (without industry sponsorship) is the equipment and resources. 010
Dilip Jayasimhan @dilipj1.bsky.social · 26/05/2025That'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. 100
Reposted by Dilip JayasimhanLars Mølgaard Saxhaug @load-dependent.eurosky.social · 26/05/2025I 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. 121
Dilip Jayasimhan @dilipj1.bsky.social · 25/05/2025I guess the question is how much we value shortening the illness over the small but catastrophic risk of a major bleed. 210
Dilip Jayasimhan @dilipj1.bsky.social · 25/05/2025Why do we not see similar issues for other indications for thrombolysis (e.g stroke or STEMI without access to PCI)? 100
Reposted by Dilip Jayasimhanjosh farkas 💊 @pulmcrit.bsky.social · 25/05/2025interesting thread with some great points here 👇 IMHO the key is having an institutional pathway about classification & management that everybody agrees on for patients in whom the treatment pathway is clear, there is no need to involve everybody (eg, if clearly not an IR candidate, why call IR?) 281
Reposted by Dilip JayasimhanSegun Olusanya (He/Him) @drfreeze.bsky.social · 25/05/2025Similar arguments could be made perhaps for “shock” teams 🤔 051
Reposted by Dilip JayasimhanLars Mølgaard Saxhaug @load-dependent.eurosky.social · 25/05/2025Could not agree more! The problem with pulmonary embolism is the lack of clear ownership (at least in my part of the world). #emimcc #cardiosky 183
Dilip Jayasimhan @dilipj1.bsky.social · 25/05/2025We often make things more complicated than they should be. 030
Dilip Jayasimhan @dilipj1.bsky.social · 25/05/2025Cardiologists don't congregate when a STEMI comes through the door, nor do neurologists when a stroke is admitted. Partly because there is ownership by one specialty, and because there is high quality evidence to guide management. Evidence rather than eminence based medicine. 1101
Dilip Jayasimhan @dilipj1.bsky.social · 25/05/2025We should instead focus our efforts more on generating high-quality evidence evaluating advanced reperfusion strategies by randomising patients into clinical trials. www.sciencedirect.com/science/arti...sciencedirect.comA prospective, multicenter, randomized controlled trial evaluating anticoagulation alone vs anticoagulation plus computer assisted vacuum thrombectomy for the treatment of intermediate-high-risk acute...Therapeutic anticoagulation (AC) is standard care for pulmonary embolism (PE). Endovascular therapy with mechanical thrombectomy (MT) is commonly perf… 351
Dilip Jayasimhan @dilipj1.bsky.social · 25/05/2025My worry is that the more people congregate over a problem, the more inclined the collective is to do more rather than less. pmc.ncbi.nlm.nih.gov/articles/PMC...pmc.ncbi.nlm.nih.govPulmonary embolism response team (PERT) implementation and its clinical value across countries: a scoping review and meta-analysisOver the last years, multidisciplinary pulmonary embolism response teams (PERTs) have emerged to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE). We ... 130
Dilip Jayasimhan @dilipj1.bsky.social · 25/05/2025Although some meta-analyses have shown benefit. All studies included are observational and at risk of the Hawthorne effect. www.sciencedirect.com/science/arti...sciencedirect.comDo Pulmonary Embolism Response Teams in Acute Pulmonary Embolism Improve Outcomes? Insights from a Meta-analysisPulmonary embolism response teams (PERTs) are being increasingly used for the management of patients admitted with acute pulmonary embolism (PE) and a… 140
Dilip Jayasimhan @dilipj1.bsky.social · 25/05/2025My unpopular opinion is that I'm skeptical about the effectiveness of PERT. 🧵 #EMIMCC 1133
Dilip Jayasimhan @dilipj1.bsky.social · 25/05/2025An interesting issue of ICU Management & Practice. From Sepsis to ARDS. #EMIMCC healthmanagement.org/c/icu/issue/...healthmanagement.orgVolume 25 - Issue 2, 2025Change content default value... 111
Dilip Jayasimhan @dilipj1.bsky.social · 23/05/2025Does this bring you any RELIEF? www.nejm.org/doi/full/10....nejm.orgRestrictive versus Liberal Fluid Therapy for Major Abdominal Surgery | NEJMGuidelines to promote the early recovery of patients undergoing major surgery recommend a restrictive intravenous-fluid strategy for abdominal surgery. However, the supporting evidence is limited, ... 010
Dilip Jayasimhan @dilipj1.bsky.social · 21/05/2025Could use a bit of atrial epicardial pacing, the rate is likely a significant contributor to the low output. 100
Dilip Jayasimhan @dilipj1.bsky.social · 18/02/2025Interestingly, no mention of acute brain injury subgroup of patients. But I'm guessing this guideline group and PICOs were determined before the publications of HEMOTION, TRAIN, and SAHaRA. 120
Dilip Jayasimhan @dilipj1.bsky.social · 13/02/2025What's your go-to quantitative measures for RV function on transthoracic and transesophageal echo? 010
Reposted by Dilip JayasimhanLars Mølgaard Saxhaug @load-dependent.eurosky.social · 09/02/2025Let’s try something different. Does anyone have any questions about acute and critical care echocardiography? If I can’t answer I’ll try to bring in someone who can. #emimcc #cccsky #pocus 8125
Dilip Jayasimhan @dilipj1.bsky.social · 30/12/2024www.criticalcare.theclinics.com/article/S074...criticalcare.theclinics.comDEFINE_ME 110
Dilip Jayasimhan @dilipj1.bsky.social · 18/12/2024Moreover, it's hard to draw definitive conclusions from observational data showing fever to be associated with improved outcomes. Which is why we perform RCTs. 020
