An audit of the role of vitamin K in the reversal of International Normalised Ratio (INR) in patients undergoing surgery for hip fracture

Abstract

INTRODUCTION The objective of this prospective audit was to compare two methods of anticoagulation reversal in the pre-operative period for hip fracture patients. PATIENTS AND METHODS In the first part of the audit, our current practice was analysed. Data relating to the number of days from admission to surgery and the reasons for delay to surgery were collected. Also, data concerning common reasons for which the patients were started on warfarin and the time required for INR to drop to 1.5 or below were collected. In the second part of the audit, 45 patients with INR above 1.5 were given a single dose of vitamin K (1 mg i.v.) in addition to stopping warfarin. RESULTS The mean difference in the time for INR < 1.5 in the two groups was 2 days (52 h; P < 0.05). The mean difference in wait for surgery since admission between the two groups was 4 days (91 h; P < 0.05). There was no significant difference between the two groups as regards the average number of co-morbidities in the patient groups. CONCLUSIONS A single 1 mg intravenous dose of vitamin K significantly reduces the time for the reversal of INR and the preoperative delay to surgery, in patients on long-term warfarin. We conclude that 1 mg of intravenous vitamin K on admission is a safe and effective treatment to avoid delay in the treatment in this group of patients.

Anticoagulation Management in Individuals with Hip Fracture

“…This differs from findings in other studies, in which statistically significant delays ranging from 12 to 62 hours were observed in time to surgery between those taking warfarin and those not taking warfarin . A prospective audit comparing hip fracture patients taking warfarin who were given 1 mg of vitamin K intravenously for an INR greater than 1.5 with those undergoing a watch and wait approach with an INR of 1.5 and above showed that a significant reduction in time to surgery can be achieved with active management . An important concept for care of individuals with hip fracture is early surgical intervention when medically stable .…”

“…9,12 A prospective audit comparing hip fracture patients taking warfarin who were given 1 mg of vitamin K intravenously for an INR greater than 1.5 with those undergoing a watch and wait approach with an INR of 1.5 and above showed that a significant reduction in time to surgery can be achieved with active management. 11 An important concept for care of individuals with hip fracture is early surgical intervention when medically stable. 16 A retrospective observational study comparing warfarin users with nonusers concluded that greater comorbidity might have delayed surgery and that an active approach can shorten wait time to surgery.…”

“…Limited evidence is available to help guide perioperative management of individuals taking warfarin, especially those who present with hip fractures, 8 and few studies have compared outcomes in individuals who are anticoagulated before surgery with those not on anticoagulation. [9][10][11][12][13] Most expert opinions recommend achieving an international normalized ratio (INR) of 1.5 or less [13][14][15] before surgery, but the authors of the current study are not aware of any studies that have correlated outcomes and preoperative INR values in individuals with hip fracture. Evidence to manage treatment of individuals with hip fracture undergoing anticoagulation with warfarin is lacking, and commonly accepted practices are derived from principles of elective surgeries.…”

“Tiers of Delay”

“…There is firm evidence both for the requirement of protocols in hip fracture care, the morbidity associated with delays to theater in patients with hip fracture on warfarin, and the benefits of IVK administration. 11,12,14,15,[28][29][30][31] In particular, Leonidou et al found that IVK administration resulted in not only a decreased delay to theater but also the lowest rate of complications. 30 It is appropriate that any broad protocol-driven path of care should be met with a degree of concern, but for the early administration of IVK in the warfarinized population with hip fracture, the wealth of evidence supports its safe and beneficial use.…”

Comparison of Different Warfarin Reversal Protocols on Surgical Delay and Complication Rate in Hip Fracture Patients

“…9 Even a small dose (1 mg) of intravenous vitamin K can reduce the mean time to surgery by a mean of 4 days. 16 The National Institute for Health and Clinical Excellence recommends that surgery be performed on the day of or after admission to achieve better outcome in terms of mortality, return to independent living, complications, and duration of hospital stay. 14 Initiatives to prevent surgical delays should be a high priority, as surgery is the best form of analgesia.…”