Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions

Abstract

Background: Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear. Methods: This was a retrospective cohort study. Geriatric patients (65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery. Results: There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p ¼ 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p ¼ 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p ¼ 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.

Recommendations from the ICM-VTE: General

“…Rationale: In general, orthopaedic surgeons are likely to face one of two scenarios that may require reversal of anticoagulation: (1) a patient who is on long-term anticoagulation (e.g., cardiac conditions) presenting with a fracture that requires urgent surgical intervention (e.g., proximal femur fracture); (2) a patient who is on short-term chemical thromboprophylaxis following an elective orthopaedic procedure (e.g., total joint arthroplasty) and develops a complication (e.g., wound breakdown or infection) or sustains a fracture that requires urgent surgical intervention. An increasing number of elderly patients on long-term anticoagulants and newer guidelines on rapid recovery surgical protocols have led to extensive research on this topic [1554][1555][1556][1557][1558][1559][1560][1561][1562][1563] . Deciding whether anticoagulation reversal is absolutely necessary or defining its specific indications are beyond the scope of this review.…”

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

“…The finding of higher transfusion rates in warfarin patients is supported by a previous study evaluating complete versus incomplete warfarin reversal in hip fracture patients, in which 25% of patients reversed to an INR < 1.5 and 39% of patients partially reversed without achieving an INR < 1.5 required packed red blood cell transfusion during hospitalization. 13 This difference was not statistically significant presumably because of low sample size of 135 patients. 13 However, there are numerous studies evaluating hip fracture patients on warfarin that have found no difference in transfusion rates between warfarin patients and non-anticoagulated patients.…”

“…However, despite active reversal, there remains highly variable drug metabolism from patient to patient, 12 and surgeons and medical comanagement colleagues must carefully balance the risk of bleeding with thromboembolic risk in the perioperative period. 13…”

“…However, despite active reversal, there remains highly variable drug metabolism from patient to patient, 12 and surgeons and medical comanagement colleagues must carefully balance the risk of bleeding with thromboembolic risk in the perioperative period. 13 In addition, patients on warfarin anticoagulation undergoing surgery for fragility hip fractures have been found to have high rates of other complications. Studies have found that chronic preoperative warfarin use is associated with higher American Society of Anesthesiologits classification, higher Charlson Comorbidity Index (CCI), and increased mortality after hip fracture surgery.…”

Proximal femur fractures in patients taking anti-coagulants: has anything changed?

“…Where is required, warfarin can be reversed by administering vitamin K or fresh frozen plasma prior to the operation. Alternatively, warfarin can be withheld and with time allowance given for the INR to drop naturally ( 17 , 34 ). The benefit of reversal of VKAs should be balanced with a possible increased risk of thrombotic complications.…”