Management of Patients Taking Oral Anticoagulants Who Need Urgent Surgery for Hip Fracture

Abstract

The number of hip fractures in anticoagulated patients is predicted to increase, due to people living longer. However, evidence regarding urgent perioperative management of elderly patients with hip fracture who take oral anticoagulants (vitamin K antagonists or direct oral anticoagulants) is scarce. In this article, the authors present a narrative review of the evidence to date supporting the urgent management of hip fracture in anticoagulated elderly patients. They discuss the complexity of managing the high risk of procedure-related bleeding and, at the same time, the high risk of thromboembolism. The role of a bridging procedure and the best strategy of anticoagulation reversal are also reviewed. Further studies are required to improve the evidence in urgent surgery, especially in frail elderly patients.

Recommendations from the ICM-VTE: General

“…For urgent surgical procedures that can be delayed for 6 - 12 hours, the anticoagulant effect of warfarin can be effectively reversed with 10 mg of intravenous vitamin K 1469-1471 . For patients requiring emergent surgical procedures (within less than 6 hours), 4-Factor PCC containing Factors II, VII, IX, and X or FFP is required to rapidly reverse the anticoagulant effect of VKA 1472,1473 . The concentration of coagulation factors in PCC is approximately 25 times greater than that available in FFP, allowing for it to be administered in small volumes of fluid 1469 .…”

“…Therefore, it is recommended that vitamin K be administered concurrently to ensure sustained reversal effect. Previous observational studies have shown that reversing the effect of VKA to an INR ≤ 1.5 using vitamin K and/or PCC or FFP is safe and effective in patients requiring emergency orthopaedic surgery 1472,1474-1478 .…”

Chronic Warfarin Anticoagulation in Hip Fracture Patients Delays Surgery and Is Associated With Increased Risk of Postoperative Complications: A Multicenter Propensity-Score–Matched Analysis

“…[4][5][6] Despite the consensus on benefits of early surgery, there remains a lack of standard practice regarding management of anticoagulated patients in the perioperative period and optimal international normalized ratio (INR) thresholds that decrease time to surgery while minimizing bleeding complications such as transfusions. 7 Current guidelines in some countries recommend delaying definitive fixation of hip fractures until the INR approximates normal levels (,1.5), whereas others report an acceptable threshold of INR , 2 unless spinal anesthesia is performed. 8 Strategies for management of elevated INR range from cessation of warfarin to active reversal with agents such as vitamin K, fresh frozen plasma, or prothrombin complex concentrate.…”

Position paper on the safety/efficacy profile of Direct Oral Anticoagulants in patients with Chronic Kidney Disease: Consensus document of Società Italiana di Nefrologia (SIN), Federazione Centri per la diagnosi della trombosi e la Sorveglianza delle terapie Antitrombotiche (FCSA) and Società Italiana per lo Studio dell’Emostasi e della Trombosi (SISET)

“…When bleeding complications occur or in case of urgent/ emergency surgery, the effect of dabigatran can be reversed using idarucizumab, whereas the activity of FXa inhibitors can be reversed by andexanet alfa, that is already on the market in the US and will be soon available in Europe. However, there is limited experience with these antidotes in clinical practice, as the number of patients so far treated is rather limited [5].…”