Impact of introducing guidelines on anticoagulant reversal

Abstract

The production of clinical guidelines has become an accepted and lauded part of modern medicine. It is also widely perceived that these guidelines provide some sort of panacea for the problems that medicine faces. Our experience suggests otherwise. Triggered by on going anecdotal evidence of poor practice, we reviewed the effect on practice of a recently introduced local guideline on the management of major bleeding in patients on warfarin. Comparing 34 patients treated before and 48 patients after the introduction of the guideline, we found no significant improvement in prothrombin complex concentrate dosing or administration of vitamin K. The only improvement witnessed was in early assessment of the effect of the intervention on coagulation which improved from 10 to 35% of cases. Of major concern, in 10% of cases, there was no documentation to confirm or refute that prothrombin complex concentrate (PCC), which had been issued, had actually been administered to the patient. The production and widespread dissemination of this local guideline did not achieve significant improvement in clinical practice. Possible reasons for failure to adhere to the guideline are discussed.

Influence of timing and oral anticoagulant/antiplatelet therapy on outcomes of patients affected by hip fractures

“…In the last several decades, patients who assume oral anticoagulant therapy have been increasing and warfarin has become commonly used, especially in patients affected by atrial fibrillation, deep vein thrombosis (DVT), or valve replacement [6][7][8]. It has been estimated that nearly 1.5% of the population is on warfarin therapy for cardiovascular disease prophylaxis [9][10][11]. The use of antiplatelet (antiaggregant) therapies such as aspirin and ticlopidine has increased also in the last few years, for example, in the secondary prevention for myocardial infarction or neurovascular diseases [12].…”

Efficacy of Warfarin Reversal in Orthopedic Trauma Surgery Patients

“…1 Current recommendations state that unless there is a very high risk of thromboembolism, anticoagulation should be temporarily discontinued in preparation for surgery. 2 Patients with an INR of greater than 2.0 are considered at higher risk during surgery because of bleeding complications.…”

An audit of the role of vitamin K in the reversal of International Normalised Ratio (INR) in patients undergoing surgery for hip fracture

“…2 Warfarin is the most commonly prescribed anticoagulant in the UK; 3 about 1-1.5% of the population in the UK is on warfarin prophylaxis. 4,5 As orthopaedic surgeons, we are faced with an increasing number of elderly anticoagulated patients who require urgent surgery for osteoporotic fractures.…”