Expedited surgery in geriatric hip fracture patients taking direct oral anticoagulants is not associated with increased short-term complications or mortality rates

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

“…Another study, which showed the largest discrepancy between the proportion of DOAC patients operated on after 48 hcompared with non-anticoagulated patients (48.9% DOAC vs 8% nonanticoagulated), also showed no difference in in-hospital or 1-ear mortality between groups (33). Multiple other studies, including a systematic review of 39 446 patients, have shown similar findings of no increased mortality risk associated with delayed surgery in DOAC users (28,29,32,34,36,37,38).…”

Section: Mortality Consequences Of Delayed Time To Surgery In Patient...mentioning

confidence: 79%

Review of perioperative outcomes and management of hip fracture patients on direct oral anticoagulants

Wall

Mitchell

et al. 2023

EFORT Open Reviews

Anticoagulation use is common in elderly patients presenting with hip fractures and has been shown to delay time to surgery (TTS). Delays in operative treatment have been associated with worse outcomes in hip fracture patients. Direct oral anticoagulants (DOACs) comprise a steadily increasing proportion of all oral anticoagulation. Currently, no clear guidelines exist for perioperative management of hip fracture patients taking DOACs. DOAC use is associated with increased TTS, with delays frequently greater than 48 h from hospital presentation. Increased mortality has not been widely demonstrated in DOAC patients, despite increased TTS. Timing of surgery was not found to be associated with increased risk of transfusion or bleeding. Early surgery appears to be safe in patients taking DOACs presenting with a hip fracture, but is not currently widely accepted due to factors such as site-specific anesthesiologic protocols that periodically delay surgery. Direct oral anticoagulant use should not routinely delay surgical treatment in hip fracture patients. Surgical strategies to limit blood loss should be considered and include efficient surgical fixation, topical application of hemostatic agents, and the use of intra-operative cell salvage. Anesthesiologic strategies have utility in minimizing risk and a collaborative effort to minimize blood loss should be undertaken by the surgeon and anesthesiologist. Anesthesia team interventions include considerations regarding positioning, regional anesthesia, permissive hypotension, avoidance of hypothermia, judicious administration of blood products, and the use of systemic hemostatic agents.

“…There was no evidence to indicate if hip fracture surgery for patients taking DOACs could reasonably be delayed, including for different types of hip fracture surgery. Sixteen retrospective cohort [22, 39–53] and four case–control studies [54–57] report the type of hip fracture surgery performed for patients taking DOACs.…”

Section: Resultsmentioning

confidence: 99%

Principles for management of hip fracture for older adults taking direct oral anticoagulants: an international consensus statement

Mitchell,

Wijekulasuriya,

Mayor

et al. 2024

Anaesthesia

SummaryHip fracture is a common serious injury among older adults, yet the management of hip fractures for patients taking direct oral anticoagulants remains inconsistent worldwide. Drawing from a synthesis of available evidence and expert opinion, best practice approaches for managing patients with a hip fracture and who are taking direct oral anticoagulants pre‐operatively were considered by a working group of the Fragility Fracture Network Hip Fracture Audit Special Interest Group. The literature and related clinical guidelines were reviewed and a two‐round modified Delphi study was conducted with a panel of experts from 16 countries and involved seven clinical specialities. Four consensus statements were achieved: peripheral nerve blocks can reasonably be performed on presentation for patients with hip fracture who are receiving direct oral anticoagulants; hip fracture surgery can reasonably be performed for patients taking direct oral anticoagulants < 36 h from last dose; general anaesthesia could reasonably be administered for patients with hip fracture and who are taking direct oral anticoagulants < 36 h from last dose (assuming eGFR > 60 ml.min‐1.1.73 m‐2); and it is generally reasonable to consider recommencing direct oral anticoagulants (considering blood loss and haemoglobin) < 48 h after hip fracture surgery. No consensus was achieved regarding timing of spinal anaesthesia. The consensus statements were developed to aid clinicians in their decision‐making and to reduce practice variations in the management of patients with hip fracture and who are taking direct oral anticoagulants. Each statement will need to be considered specific to each individual patient's treatment.