Is There a Safe Way to Reverse Anticoagulation in Patients With Hypercoagulable State?

Abstract

Acute hip fracture is deemed an emergent orthopedic intervention, such interventions can be complicated if the patient is on anticoagulation for chronic thromboembolic disease. We are presenting a case of an elderly patient who presented with an acute hip fracture with an elevated INR that required rapid reversal, which unfortunately led to a fatal thromboembolic event. CASE PRESENTATION:The patient 80 year-old female with PMH of DVT, PE, and Factor V Leiden on warfarin was admitted for management of an acute hip fracture. On presentation, her INR was 4, and was given vitamin K for INR reversal. Intraoperatively, there were no acute events. The following morning, the patient was found to be less responsive. The laboratory studies revealed high anion gap metabolic acidosis secondary to elevated lactate indicative of bowel ischemia. The patient was intubated due to worsening mentation. Her CTA of abdomen and chest was significant for moderate to severe stenosis of celiac axis, severe narrowing of splenic, common hepatic artery and gastric artery. Unfortunately, she eventually was placed in comfort care.DISCUSSION: Any acute stress including trauma can induce systemic inflammation leading to an increased risk of thromboembolism. Immunothrombosis describes an activation of neutrophils usually triggered by recognition of damaged cells, specifically neutrophils extracellular traps (NETs) and their interaction with various intracellular and extracellular proteins triggering coagulation cascade. Therefore, in a patient with underlying coagulopathy requiring lifelong anticoagulation an extreme caution must be taken while reversing anticoagulation. CONCLUSIONS:Our patient underwent an emergent hip replacement surgery after reversal of warfarin, however due to her underlying hypercoagulable state and recent surgery, she suffered from multiple thrombotic events that eventually led to her demise. There are no guidelines that provide the most appropriate way to reverse anticoagulation in patients with underlying hypercoagulable state. 1 out of 500 people suffer from an underlying disease that puts them at risk of thromboembolic events. It is imperative to develop guidelines for reversal of anticoagulation in patients with diseases that places them at risk of hypercoagulable state to ensure safety while undergoing surgical procedures.