Delayed Surgery Does Not Reduce Transfusion Rates in Low-Energy Hip Fractures on Direct Oral Anticoagulants

Weaver

et al. 2023

J Am Acad Orthop Surg

Orthogeriatric hip fractures have high morbidity and mortality rates. Modern management focuses on multidisciplinary collaboration for prompt surgical stabilization, early mobilization with multimodal pain control to avoid opioid consumption, and an enhanced recovery pathway. Despite these advances, postoperative complications and mortality rates remain higher than age-matched control subjects. The authors of this article represent the orthopaedic, anesthesia, and hospitalist medicine members of a multidisciplinary team at a single, Level 1 trauma center. Our goal was to provide an up-to-date comprehensive review of orthogeriatric hip fracture perioperative management from a multidisciplinary perspective that every orthopaedic surgeon should know. Improved life expectancy and activity levels in the elderly means the number of geriatric hip fractures requiring surgery are increasing. Changing population demographics predict that by 2040 1 in 4 Europeans and 1 in 5 North Americans will be older than 65 years. 1 Despite care advancements, geriatric hip fractures are a common cause of morbidity and mortality and a notable source of costs to healthcare systems. Updated information suggests that the average geriatric femur fracture spends 5.8 days inpatient and costs around $16,423 in the United States. In addition, patients with femur fracture have a 10% chance of death in the first 30 days and 8% to 36% up to a year after repair. 2,3 Higher mortality rates persist for geriatric hip fractures versus age and comorbidity-matched cohorts as long as 10 years after fracture. 1 Geriatric hip fractures are best served by an orthogeriatric approach with a multidisciplinary care team. They have a greater number of comorbid conditions than other surgical patients. Perioperative risk is affected by timing of surgery. Time to surgery beyond 24-48 hours from injury is associated with increased morbidity and mortality. [4][5][6] This creates a dilemma wherein patient risk factors and perisurgical evaluation and optimization must be balanced with avoidance of unnecessary delays to surgery. Integrating a dedicated geriatric femur fracture perioperative care pathway with a surgical and medicine comanagement model is an invaluable solution. [7][8][9] Members of a comanagement team can include representatives from orthopaedics, anesthesia, medicine/geriatrics, rehab therapy, and nursing coordinators. Comanagement should focus on coeducation between specialists; evidence-based standardization of care

Section: Intraoperative Managementmentioning

confidence: 78%

Current Strategies in Medical Management of the Geriatric Hip Fracture Patient

Weaver

et al. 2023

J Am Acad Orthop Surg

Journal of Orthopaedic Trauma

“…Our results contribute to a growing body of literature suggesting that DOACs do not meaningfully increase blood loss in this patient population. 11 This is particularly important for these drugs that can have relatively long half-lives and high-cost reversal agents with limited availability. 24 Importantly, the length of stay in this group did not differ from patients not taking anticoagulants, implying that blood loss in this group was not artificially depressed by delaying surgery until the effect of these medications had worn off.…”

Section: Discussionmentioning

confidence: 99%

“…The data presented support a growing literature that surgical intervention for extracapsular geriatric hip fractures should not be delayed for patients taking anticoagulants. 11,17 Surprisingly, antiplatelet drugs including aspirin were more strongly associated with increased blood loss than anticoagulants. Because the increased blood loss from antiplatelet medications did not increase early postoperative mortality and anticoagulants did not meaningfully increase blood loss, early hip fracture fixation for patients taking anticoagulant drugs without reversal may be warranted to avoid the known risks of surgical delay.…”

Section: Discussionmentioning

confidence: 99%

“…The scarce literature available recommends delaying surgery up to 48 hours for patients taking these drugs. [10][11][12] Similarly, patients taking antiplatelet therapies (eg, aspirin or clopidogrel) to reduce cardiovascular events may face a choice between increased blood loss and delayed hip fracture surgery. [13][14][15] Timely intervention for hip fractures is paramount to permit early ambulation and reduce complications including mortality.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Full Reversal of Anticoagulants Before Cephalomedullary Fixation of Geriatric Hip Fractures May Not Be Necessary

Maturana

Perdue²,

Ahn³

et al. 2023

Objectives: To examine the relationship between anticoagulant and antiplatelet drugs and surgical blood loss for geriatric patients undergoing cephalomedullary nail fixation of extracapsular proximal femur fractures. Design: Multicenter, retrospective, cohort study using bivariate and multivariable regression analyses. Setting: Two Level-1 trauma centers. Patients: One thousand four hundred forty-two geriatric (ages 60–105 years) patients undergoing isolated primary intramedullary fixation of nonpathologic extracapsular hip fractures from 2009 to 2018 including 657 taking an antiplatelet drug alone (including aspirin), 99 taking warfarin alone, 37 taking a direct oral anticoagulant (DOAC) alone, 59 taking an antiplatelet drug and an anticoagulant, and 590 taking neither. Intervention: Cephalomedullary nail fixation. Main Outcome Measurements: Blood transfusion and calculated blood loss. Results: More patients taking antiplatelet drugs required a transfusion than controls (43% vs. 33%, P < 0.001), whereas patients taking warfarin or DOACs did not (35% or 32% vs. 33%). Median calculated blood loss was increased in patients taking antiplatelet drugs (1275 mL vs. 1059 mL, P < 0.001) but not in patients taking warfarin or DOACs (913 mL or 859 mL vs. 1059 mL). Antiplatelet drugs were independently associated with an odds ratio of transfusion of 1.45 [95% confidence interval (CI), 1.1–1.9] in contrast with 0.76 (95% CI, 0.5–1.2) for warfarin and 0.67 (95% CI, 0.3–1.4) for DOACs. Conclusions: Geriatric patients taking warfarin (incompletely reversed) or DOACs lose less blood during cephalomedullary nail fixation of hip fractures than those taking aspirin. Delaying surgery to mitigate anticoagulant-related surgical blood loss may be unwarranted. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OTA International: The Open Access Journal of Orthopaedic Trauma

“…[2][3][4][5][6][7][8][9] However, delayed surgery has not been shown to decrease transfusion rates, bleeding, or complications. 3,5,10,11 Recently published guidelines for patients with atrial fibrillation receiving factor Xa inhibitors recommend waiting 48 hours after the last dose to undergo surgery with high bleeding risk (eg, hip fracture surgery) to minimize blood loss. 12 However, the study does not provide recommendations for patients with decreased renal function because factor Xa inhibitors are renally cleared.…”

Section: Introductionmentioning

confidence: 99%

Expedited surgery does not increase transfusion rates for patients with geriatric hip fracture taking factor Xa inhibitors

Wang,

Nilssen,

Stone

et al. 2024

Objectives: Geriatric patients who sustain hip fractures and are taking factor Xa inhibitors (Xa-I) experience surgical delay. Our institution developed a pharmacokinetic protocol to formally guide and expedite surgical timing for these patients. The protocol is based on the patient's renal function and timing of last Xa-I dose. For patients with impaired renal function, longer wait times are recommended. The purpose of this study was to determine the effects of this protocol for patients with geriatric hip fracture taking Xa-I. Design: Retrospective cohort study. Setting: Level 1 trauma center. Patients/Participants: A total of 164 patients aged 65 and older who were taking Xa-I before admission and underwent hip fracture surgery; 68 patients in the Standard group (2014–2018) and 96 patients in the Expedited group (2020–2022, after protocol implementation). Intervention: Hip fracture surgery. Main Outcome Measurements: Time to surgery (TTS), transfusion rate, blood loss, 90-day complication rates. Results: The median TTS was significantly shorter in the Expedited group (28.6 hours, interquartile range 21.3 hours) than in the Standard group (44.8 hours, interquartile range 21.1 hours) (P < .001). There were no differences in overall transfusion rates. Multivariable regression analysis demonstrated that time to surgery was not predictive of transfusion rate in all patients (OR 1.00, 95% CI 0.99–1.02, P = .652). There were no differences in blood loss or rates of 90-day complications. Conclusion: Geriatric patients with hip fractures and taking factor Xa inhibitors may warrant earlier surgery without an increased risk of transfusion or bleeding. Level of Evidence: Therapeutic Level III.