In this viva, the focus of the question will be on Evidence Based Medicine

Please read this modified abstract of a study recently published in the New England Journal of Medicine

Decompressive Craniectomy in Diffuse Traumatic Brain Injury

Background

It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure.

Methods

Of 3478 patients screened, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first-tier therapies to undergo either decompressive craniectomy or standard care. Intracranial hypertension was defined in the study as an increase in intracranial pressure above 20 mm Hg for more than 15 minutes. Patients with intracranial mass lesions were excluded from the study.

Results

Patients in the craniectomy group had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02), and fewer days in the intensive care unit (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P = 0.03) and a greater risk of an unfavourable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P = 0.02). Rates of death at 6 months were similar in both groups.

Conclusions

In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavourable outcomes.

1. A colleague says this study shows that decompressive craniectomy should be abandoned for traumatic brain injury. Do you agree?

The rest of the viva focussed on EBM and critical appraisal of the literature

Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.