Direct oral anticoagulants and delays to hip fracture repair

Mayor, Amy; White, Stuart

doi:10.1111/anae.15008

Cited by 4 publications

(3 citation statements)

References 27 publications

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“…Multiple recent studies challenge this idea, with no difference found in transfusion rates and postsurgical hemoglobin changes between patients on DOACs and propensity-matched, uncoagulated cohorts. 30-33 We conclude that there is little evidence supporting routine delay for hip fracture fixation because of DOACs. Based on these studies, the harm from delaying surgery >24 to 48 hours may be greater than the risk of increased perisurgical bleeding from DOAC therapy.…”

Section: Intraoperative Managementmentioning

confidence: 80%

Current Strategies in Medical Management of the Geriatric Hip Fracture Patient

Zuelzer

Weaver

Zuelzer

et al. 2023

J Am Acad Orthop Surg

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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

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Section: Intraoperative Managementmentioning

confidence: 80%

Current Strategies in Medical Management of the Geriatric Hip Fracture Patient

Zuelzer

Weaver

Zuelzer

et al. 2023

J Am Acad Orthop Surg

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“…Although 80% of minor haemorrhages occurred at the puncture site prior to the administration of thromboprophylaxis in superficial continuous blocks (femoral), no major haemorrhages were observed in deep continuous blocks (lumbar and sciatic). Minor hemorrhage risk was estimated to be 1.3%, with 0.2% attributed to the PNB 194 . The association of femoral and sciatic blocks has been advocated as a well tolerated alternative to neuraxial blocks in anticoagulated patients for lower limb anaesthesia 195,196 .…”

Section: Discussionmentioning

confidence: 99%

“…Minor hemorrhage risk was estimated to be 1.3%, with 0.2% attributed to the PNB. 194 The association of femoral and sciatic blocks has been advocated as a well tolerated alternative to neuraxial blocks in anticoagulated patients for lower limb anaesthesia. 195,196 Continuous peripheral catheters were also considered well tolerated in combat casualties prescribed LMWH.…”

Section: Recommendation 38mentioning

confidence: 99%

Regional anaesthesia in patients on antithrombotic drugs

Kietaibl

Ferrandis

Godiér

et al. 2022

European Journal of Anaesthesiology

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BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.

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