Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications

Schermann, Haggai; Gurel, Ron; Gold, Aviram; Maman, Eran; Dolkart, Oleg; Steinberg, Ely L.; Chechik, Ofir

doi:10.1016/j.injury.2018.10.033

Cited by 59 publications

(80 citation statements)

References 17 publications

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“…Despite this increased comorbidity, we were not able to find increased risk of perioperative blood loss, transfusion rates, bleeding complications or mortality for the DOAC-users compared to the less comorbid non-users. Our findings are in contrast to another study reporting a higher one-year mortality among hip fracture patients using DOAC compared to non-users [24]. However, the excess mortality may be explained by higher age, more comorbidity and longer surgical delay than in our patients.…”

Section: Discussioncontrasting

confidence: 99%

Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

et al. 2020

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The aim of this study was to determine whether DOAC-users with a hip fracture have delayed surgery, longer length of hospital stay or altered risk of bleeding complications compared to non-users. Findings DOAC-users with a hip fracture did not have increased surgical delay, length of stay or risk of reported bleeding complications compared to patients without anticoagulation prior to surgery. Message Our study does not support delayed surgery for DOAC-users suffering a hip fracture.

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Section: Discussioncontrasting

confidence: 99%

Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

et al. 2020

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“…Several further studies have been performed investigating perioperative DOAC use in hip fractures, however, have included patients operated on outside the recommended 48 hours where the anticoagulant effect will likely be eliminated or significantly reduced. [27][28][29] Strengths of this study involve the strict controls and exclusion criteria that were utilized at the cost of extra patient numbers. To the authors' knowledge, this is the only study to directly compare DOAC patients operated on <48 hours to those operated on >48 hours and to a nonanticoagulated control.…”

Section: Discussionmentioning

confidence: 99%

Early Surgical Fixation for Hip Fractures in Patients Taking Direct Oral Anticoagulation: A Retrospective Cohort Study

King

Polischuk

Lynch

et al. 2020

Geriatr Orthop Surg Rehabil

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Introduction: Currently, evidence-based guidelines regarding delay to theatre for urgent surgical intervention in patients taking direct oral anticoagulants (DOACs) are lacking. Therefore, this study aims to investigate the effect of DOACs on patient outcomes receiving early (<48 hours) versus delayed (>48 hours) surgery for neck of femur fractures. Methods: A retrospective cohort study was conducted at a tertiary teaching hospital. Treatment groups were hip fracture patients taking DOACs on admission and receiving surgery in <48 hours (n = 17) and >48 hours (n = 11). A control cohort of hip fracture patients not taking DOACs (n = 56) was matched to the <48 hours treatment group for comparison. Patient demographics were recorded and key outcome measures included perioperative hemoglobin levels, transfusion rates, time to surgery, 90-day mortality, hematoma rates, and length of stay in hospital. Results: There was no significant difference in perioperative hemoglobin levels, transfusion rates, or hematoma between groups. Patients taking DOACs and receiving early surgery had significantly longer time to surgery compared to the non-DOAC control (32.21 ± 7.83 vs 25.98 ± 11.4, P = .01). No deaths were recorded in the early DOAC group at 90 days, compared to 4 (36%) in the late DOAC group ( P = .04). Discussion and Conclusions: Our study suggests hip fracture patients taking DOACs on admission is not a reason to delay surgery. However, given the lack of literature in this area, further prospective research with larger patient numbers is required to definitively guide clinical practice.

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“…The study has larger numbers than the existing literature (n = 7 [6], n = 19 [7], n = 27 [8], n = 28 [9], n = 29 [10], n = 33 [16], n = 47 [11], n = 52 [15], n = 54 [12], n = 63 [13] and n = 89 [14]). It also specifically focuses on assessing a dose-response relationship within a cohort taking DOACs; this approach avoids the potential bias of finding a suitable non-DOAC control group and should be considered for future studies.…”

Section: Discussionmentioning

confidence: 93%

“…The existing literature compares hip fracture groups with matched cohorts not taking anticoagulants [7][8][9][11][12][13][14] or groups' DOACs with other antithrombotics without separate analysis [6,10]. The most common management question asked by clinicians is ''what is the safest window to operate?".…”

Section: Discussionmentioning

confidence: 99%

“…National pharmaceutical subsidies have resulted in a steady increase in usage [5]. The existing literature examining DOAC use in hip fracture is small [6][7][8][9][10][11][12][13][14][15][16], and often focuses on comparing DOAC cohorts with groups not taking them, which results in differences between group comorbidity profiles. The appropriate perioperative management for DOACs in hip fracture has been recently queried [17], with expert opinion suggesting a waiting period of 24-48 hours, based on DOAC half-lives and guidelines for elective surgery [18].…”

Section: Introductionmentioning

confidence: 99%

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Direct Oral Anticoagulants and Timing of Hip Fracture Surgery

Tarrant

Catanach

Sarrami

et al. 2020

JCM

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Timely surgical intervention in hip fracture has been linked to improved outcomes. Direct Oral Anticoagulants (DOACs) are an emerging class of anticoagulants without evidence-based guidelines on surgical timing. This study aims to investigate how DOACs affect surgical timing and hence perioperative outcomes. A retrospective database/registry review was conducted for geriatric hip fracture patients aged 65 and over between 2011 and 2018. Primary outcome was 30-day mortality. Secondary outcomes included serious adverse events (SAE), transfusion and postoperative day (POD) 1 haemoglobin (Hb) levels. From a cohort of 3264 patients, 112 admitted subjects were taking DOACs; the annual proportion on DOACs increased over time. Mean time to surgery from last dose (Ts) was 2.2 (±1.0 SD) days. The primary outcome, 30-day mortality, occurred in 16 (14%) patients with secondary outcomes of SAEs in 25 (22%) patients and transfusion in 30 (27%) patients. Ts (days) did not significantly affect 30-day mortality (odds ratio (OR): 1.37, 95% confidence interval (CI): 0.80–2.33; p = 0.248), SAE (hazard ratio (HR): 1.03, 95% CI: 0.70–1.52; p = 0.885), transfusion (OR: 0.72 95% CI: 0.45 to 1.16; p = 0.177) or POD 1 Hb (OR: 1.99, 95% CI: −0.59 to 4.57; p = 0.129). Timing of surgery does not influence common surgical outcomes such as 30-day mortality, SAE, transfusion, and POD1 Hb in patients taking DOACs on admission.

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Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications

Cited by 59 publications

References 17 publications

Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients?

Early Surgical Fixation for Hip Fractures in Patients Taking Direct Oral Anticoagulation: A Retrospective Cohort Study

Direct Oral Anticoagulants and Timing of Hip Fracture Surgery

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