Delayed Time to Emergency Hip Surgery in Patients Taking Oral Anticoagulants

Cafaro, Teresa; Tagalakis, Vicky; Koolian, Maral; Simard, Camille

doi:10.1182/blood-2019-128849

Cited by 3 publications

(4 citation statements)

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“…First, none of the included studies accounted for the competing risk of death with each endpoint. This is relevant given the association between time to surgery, pre‐injury anticoagulation status, and mortality 8,33 . Nonetheless, there was consistency in directionality between different endpoints in our study, whereby increased estimated blood loss among anticoagulated patients led to the same group requiring higher transfusion utilization.…”

Section: Discussionsupporting

confidence: 50%

“…Of the 4015 abstracts identified following removal of duplicates, 3924 studies were excluded following title and abstract screening (Figure 1). Of the remaining 91 studies which underwent full‐text review, 21 studies were determined to be eligible and included in the systematic review 8,9,21‐39 . They comprised 7605 anticoagulated hip fracture patients and 13 812 non‐anticoagulated patients (Table 1).…”

Section: Resultsmentioning

confidence: 99%

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Effect of oral anticoagulants on hemostatic and thromboembolic complications in hip fracture: A systematic review and meta‐analysis

You

Krzyzaniak

et al. 2020

Journal of Thrombosis and Haemostasis

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Background: Hip fracture patients on oral anticoagulants (OACs) experience increased time-to-surgery and higher mortality compared to non-anticoagulated patients. However, it is unclear whether pre-injury OAC status and its associated operative delay are associated with worsening of peri-operative hemostasis or an increased risk of postoperative thromboembolism. Methods: We performed a systematic review to identify studies that directly compared hemostatic and thromboembolic outcomes among hip fracture patients on an OAC prior to admission with those not on anticoagulants. Random effects metaanalyses were used to pool all outcomes of interest (estimated blood loss, transfusion requirements, and postoperative thromboembolism). Results: Twenty-one studies involving 21 417 patients were included. Estimated blood loss was higher among patients presenting with OACs compared to those not anticoagulated (mean difference 31.0 mL, 95% confidence interval [CI] 6.2-55.7). Anticoagulated patients also had a 1.3-fold higher risk of receiving red blood cell transfusions (odds ratio [OR] 1.34, 95% CI 1.20-1.51); however, rates of postoperative thromboembolism were similar regardless of anticoagulation status (OR 0.96, 95% CI 0.40-2.79 for venous thromboembolism; OR 0.58, 95% CI 0.25-1.36 for arterial thromboembolism). No subgroup effect was found based on anticoagulant type or degree of surgical delay. Conclusion: Hip fracture patients on OACs experience increased surgical blood loss and higher risk of red blood cell transfusions. However, the degree of surgical delay did not mitigate this risk, and there was no difference in postoperative thromboembolism. The impact of appropriate, timely OAC reversal on blood conservation and expedited surgery in anticoagulated hip fracture patients warrants urgent evaluation. | 2567 XU et al.

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Section: Discussionsupporting

confidence: 50%

Section: Resultsmentioning

confidence: 99%

Effect of oral anticoagulants on hemostatic and thromboembolic complications in hip fracture: A systematic review and meta‐analysis

You

Krzyzaniak

et al. 2020

Journal of Thrombosis and Haemostasis

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“…13,14 Extensive research has shown that delay to surgery is associated with increased morbidity, mortality, and length of stay in hospital. 15 -19 Despite these findings, patients on DOACs have increased delays to surgery compared to patients on no anticoagulation or on vitamin K antagonists. Average time to surgery for DOAC patients has been shown to vary from 35 hours to 66.9 hours.…”

Section: Introductionmentioning

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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“…Given these uncertainties, it is unsurprising that hip fracture patients taking DOACs experience delays to surgery up to three times longer than non‐anticoagulated patients . Nationally, 6.9% of delays to surgery in the UK are attributable specifically to DOACs; this equates to ~1400 patient delays annually, suggesting that virtually all of the patients receiving DOACs experience delays > 36 h to surgery .…”

mentioning

confidence: 99%