26th June 2014  DECRA

Presented By Dr Stephen Bishop

At least once each week we discuss whether to perform a decompressive crainectomy (DC) on one of our patients. However, for such a major procedure there is very little good quality evidence to support its use. DECRA is the only large RCT examining the use of decompression to treat refractory ICP and it is a useful time to examine the paper now that RescueICP has finished recruiting.

DECRA collected data over 7 years, primarily in Australia and New Zealand, with the majority of patients coming from a single centre in Melbourne. It specified a very limited group of patients and determined that whilst DC was effective at lowering ICP it was associated with harm. Such a significant, contentious study has unsurprisingly generated a lot of comment and debate and there is a wide variety of background reading this week.

Some videos below, firstly a lecture by Simon Finfer, from RNSH in Sydney, delivered when DECRA came out and he covers the background and interpretation of the trial. Then a lecture by Jamie Cooper, one of the lead authors of DECRA, discussing ANZCA research where he talks about how DECRA can be interpreted.

A review in the Lancet from 2012 was part of a series of three on trauma management and puts DC in the context of the other aspects of trauma medicine but perhaps more interesting is this review by Andrew Maas which discusses the whole gamut of TBI management. An accompanying NEJM editorial for DECRA which touches on a couple of the problems with the DECRA. This review by our surgical colleagues at Cambridge gives a much wider perspective on the procedure than the view we perhaps take within intensive care medicine and complements this recent NEJM review which was part of a series of reviews on intensive care medicine. More broadly, we discussed ICP and its treatment at an earlier journal club.

In addition to the useful journal club discussion, one area which might be useful to to discuss at journal club is how RescueICP differs from DECRA and whether these differences will address some of the criticisms of DECRA.

Some other questions which we do not know the answers to are:

If we are to decompress which operation should we perform, how do the operations differ?

What about late DC, how late is late and should we ever do it?

If DC does cause harm, what are the mechanisms and can we identify which patients are at risk?


Follow-up


Some other background resources:

Review from Stanford.

Review from Birmingham.

JICS review.

Comments and letters in NEJM following DECRA.


 

Simon Finfer on TBI and DECRA, part 1

Part 2

Part 3

 

Jamie Cooper talking about ANZICS research including DECRA at the Victorian Intensive Care Network.