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

Abstract

purpose. To compare the effects of different warfarin reversal protocols on surgical delay and complication rate in hip fracture patients. Methods. Records of 7 men and 17 women aged 68 to 93 (mean, 82) years who were on warfarin and underwent surgery for femoral neck fractures were reviewed. The time to surgery, complication rate, and mortality were recorded, as were the International Normalised Ratio (INR) on admission and the day of operation, as well as the dose, route, and time of administration of vitamin K for reversing the anticoagulation effect of warfarin. Patients were divided into 4 groups based on the warfarin reversal treatment. Group 1 (n=4) included patients who did not receive reversal treatment, as their admission INR was ≤1.5. Group 2 (n=6) included patients who did not receive reversal treatment even though their INR was >1.6. Group 3 (n=5) included patients who received inappropriate reversal treatment (late or low-dose oral administration). Group 4 (n=9) included patientsComparison of different warfarin reversal protocols on surgical delay and complication rate in hip fracture patients who received appropriate reversal treatment in terms of dose, route, and time of administration. results. Among the 4 groups, the mean INR was 2.2 (range, 1.3-4.6) on admission and 1.4 (range, 1.0-1.6) on the day of surgery. Group 1 was excluded from further analysis. Respectively in groups 2, 3, and 4, the mean times to surgery were 2.3, 2.6, and 1.2 days, and the complication rates were 67%, 20%, and 11%. conclusion. Early administration of intravenous vitamin K for hip fracture patients on warfarin is recommended to ensure early operative management and avoid postoperative complications.

“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.…”

Budget Impact Analysis of Warfarin Reversal Therapies Among Hip Fracture Patients in Finland

“…The spontaneous reversal of anticoagulation by temporary warfarin cessation takes several days. As warfarin acts as a vitamin K antagonist, the reversal of anticoagulation is achieved more rapidly with the concomitant administration of oral vitamin K [7, 16, 17]. If 1 mg of oral vitamin K is given 24 h before surgery, an INR ratio can be normalized in some patients and correlates with short duration of bridging therapy [18].…”

CORR Insights®: Do Patients Taking Warfarin Experience Delays to Theatre, Longer Hospital Stay, and Poorer Survival After Hip Fracture?

“…As of today, there are no widely accepted guidelines for pharmacologic reversal of warfarin in patients requiring hip fracture surgery. Some authors suggested administration of vitamin K as a safe, effective, and cost-efficient method of reversing warfarin in patients undergoing hip fracture surgery [1,[5][6][7][8]. However, the ideal dosage, dosing schedule, and route of administration (oral versus subcutaneous or intravenous) remain unknown.…”

“…Different approaches for warfarin reversal in patients with hip fracture have been suggested [1,2,[5][6][7][8]10]. Available options include prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), and vitamin K [7].…”