Warfarin, not direct oral anticoagulants nor antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: implications in this new era of novel anticoagulants: An EAST Multicenter study.

INTRODUCTION: To assess perioperative bleeding complications & in-hospital mortality in patients requiring emergency general surgery (EGS) presenting with a history of antiplatelet (AP) vs. direct oral anticoagulant (DOAC) vs warfarin use. METHODS: Prospective observational study across 21 centers between 2019-2022. Inclusion criteria were age ≥ 18 years, & DOAC, warfarin or AP use within 24 hours of an EGSP. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using ANOVA, Chi-square, and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, & 40 (9.7%) warfarin use. Most common indications for surgery were obstruction (23% (AP), 45% (DOAC), 28% (warfarin)), intestinal ischemia (13%, 17%, 23%), & diverticulitis/peptic ulcers (7%, 7%, 15%). Compared to DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (OR 4.4 [2.0, 9.9]). There was no significant difference in perioperative bleeding complication between DOAC & AP use (OR 0.7 [0.4, 1.1]). Compared to DOAC use, there was no significant difference in mortality between warfarin use (0.7 [0.2, 2.5]) or AP use (OR 0.5 [0.2, 1.2]). After adjusting for confounders, warfarin use (OR 6.3 [2.8, 13.9]), medical history and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR 1.3 [0.39, 4.7]), whereas intraoperative vasopressor use (OR 4.7 [1.7, 12.8)), medical history & postoperative bleeding (OR 5.5 [2.4, 12.8]) were. CONCLUSIONS: Despite ongoing concerns about the increase in DOAC use & lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease & comorbidities rather than type of antiplatelet or anticoagulant use.

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study.

BACKGROUND: While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS: This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS: Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION: Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Nerve monitoring decreases recurrent laryngeal nerve injury risk for neoplasm-related thyroidectomy.

OBJECTIVE: Conflicting reports exist regarding the benefit of intraoperative neuromonitoring (INM) for patients undergoing thyroidectomy. We hypothesized that in a national sample, the risk of mild and severe RLNi is decreased for patients undergoing neoplasm-related disease (NRD) thyroidectomy with INM compared to patients without INM. METHODS: The database was queried for patients that underwent total thyroidectomy for NRD with and without INM. A multivariable logistic regression model was used to determine the associated odds of RLNi. RESULTS: From 6942 patients, 4269 (61.5%) had INM during thyroidectomy. Patients with INM had a similar rate of overall RLNi compared to patients without INM (5.7% vs. 6.6%, p = 0.118). After adjusting for covariates, INM was associated with decreased odds of severe-RLNi (OR 0.23, p = 0.036) but not mild-RLNi (p = 0.16). CONCLUSION: INM is associated with a nearly 80% decreased associated odds of severe RLNi during thyroidectomy for NRD. Future prospective confirmation is needed, and if confirmed, patients undergoing thyroidectomy for NRD should have INM to reduce the risk of RLNi and its associated morbidity.

Early cognitive impairment is common in pediatric patients following mild traumatic brain injury.

INTRODUCTION: The incidence and factors related to early cognitive impairment (ECI) after mild traumatic brain injury (mTBI) in pediatric trauma patients (PTPs) are unknown. Prior data in the adult population demonstrated an ECI incidence of 51% after mTBI and strong correlation with initial Glasgow Coma Scale (GCS) and Brain Injury Guidelines (BIG) category. Therefore, we hypothesized that ECI is common after mTBI in PTPs and associated with initial GCS and BIG category. METHODS: A single-center, retrospective review of PTPs (age, 8-17 years) from 2015 to 2019 with intracranial hemorrhage and mTBI (GCS score, 13-15) was performed. Primary outcome was ECI, defined as Ranchos Los Amigos score less than 8. Comparisons between ECI and non-ECI groups regarding Injury Severity Score (ISS), demographics, and cognitive and clinical outcomes were evaluated using χ2 statistics and Wilcoxon rank sum tests. Odds of ECI were evaluated using multivariable logistic regression. RESULTS: From 47 PTPs with mTBI, 18 (38.3%) had ECI. Early cognitive impairment patients had a higher ISS than non-ECI patients (19.7 vs. 12.6, p = 0.003). Injuries involving motor vehicles were more often related to ECI than non-auto-involved mechanisms (55% vs. 15%, p = 0.005). Lower GCS score (odds ratio [OR], 6.60; 95% confidence interval [CI], 1.34-32.51, p = 0.02), higher ISS (OR, 1.12; 95% CI, 1.01-1.24; p = 0.030), and auto-involved injuries (OR, 6.06; 95% CI, 1.15-31.94; p = 0.030) were all associated with increased risk of ECI. There was no association between BIG category and risk of ECI (p > 0.05). CONCLUSION: Nearly 40% of PTPs with mTBI suffer from ECI. Lower initial GCS score, higher ISS, and autoinvolved mechanism of injury were associated with increased risk of ECI. Brain Injury Guidelines category was not associated with ECI in pediatric patients. LEVEL OF EVIDENCE: Prognostic study, Level III.

An interview study with medical scribes on how their work may alleviate clinician burnout through delegated health IT tasks.

OBJECTIVES: To understand how medical scribes' work may contribute to alleviating clinician burnout attributable directly or indirectly to the use of health IT. MATERIALS AND METHODS: Qualitative analysis of semistructured interviews with 32 participants who had scribing experience in a variety of clinical settings. RESULTS: We identified 7 categories of clinical tasks that clinicians commonly choose to offload to medical scribes, many of which involve delegated use of health IT. These range from notes-taking and computerized data entry to foraging, assembling, and tracking information scattered across multiple clinical information systems. Some common characteristics shared among these tasks include: (1) time-consuming to perform; (2) difficult to remember or keep track of; (3) disruptive to clinical workflow, clinicians' cognitive processes, or patient-provider interactions; (4) perceived to be low-skill "clerical" work; and (5) deemed as adding no value to direct patient care. DISCUSSION: The fact that clinicians opt to "outsource" certain clinical tasks to medical scribes is a strong indication that performing these tasks is not perceived to be the best use of their time. Given that a vast majority of healthcare practices in the US do not have the luxury of affording medical scribes, the burden would inevitably fall onto clinicians' shoulders, which could be a major source for clinician burnout. CONCLUSIONS: Medical scribes help to offload a substantial amount of burden from clinicians-particularly with tasks that involve onerous interactions with health IT. Developing a better understanding of medical scribes' work provides useful insights into the sources of clinician burnout and potential solutions to it.

A national analysis of pediatric firearm violence and the effects of race and insurance status on risk of mortality.

OBJECTIVES: To perform a national analysis of pediatric firearm violence (PFV), hypothesizing that black and uninsured patients would have higher risk of mortality. METHODS: The Trauma Quality Improvement Program (2014-2016) was queried for PFV patients ≤16 years-old. Multivariable logistic regression models on all patients and a subset excluding severe brain injuries were performed. RESULTS: The PFV mortality rate was 11.2%. 66.5% of PFV patients were black (p < 0.001). Deceased patients were more likely to be uninsured (14.5% vs. 5.3%, p < 0.001). Black race was an associated risk factor for mortality in patients without severe brain injury (OR 5.26, CI 1.00-27.47, p = 0.049) but not for the overall population (OR 1.32, CI 0.68-2.56, p = 0.39). CONCLUSION: Nearly two-thirds of PFV patients were black. Contrary to previous studies, black and uninsured pediatric patients did not have an increased risk of mortality overall. However, in a subset of patients without severe brain injury, black race was associated with increased mortality risk. SUMMARY: Between 2014 and 2016 the mortality rate for pediatric firearm violence (PFV) in children 16 years and younger was 11.2%. Although two-thirds of PFV patients were black, black race and lack of insurance were not risk factors of mortality for the overall population. Once patients with severe brain injury were excluded, black race and became associated with an increased risk of mortality.