Should surgery be delayed in patients taking direct oral anticoagulants who suffer a hip fracture? A retrospective, case-controlled observational study at a UK major trauma centre

Abstract

ObjectiveTo determine whether not waiting for the elimination of direct oral anticoagulants (DOACs) has an effect on the amount of perioperative bleeding in patients who undergo operative treatment of a hip fracture.DesignObservation, retrospective case–control study.SettingA single UK major trauma centre.ParticipantsPatients who sustained a hip fracture were identified using the National Hip Fracture Database (NHFD). All those found to be taking a DOAC at the time of fracture were identified (n=63). A matched group not taking a DOAC was also identified from the NHFD (n=62).Main outcomePerioperative drop in haemoglobin concentration.ResultsThere was no relationship between admission to operation interval and perioperative change in haemoglobin concentration in patients taking DOACs (regression coefficient=−0.06 g/L/hour; 95% CI −0.32–0.20; p=0.64). No relationship was found between the time from admission to operation interval and the probability of transfusion (OR=0.94; 95% CI 0.85 to 1.90; p=0.16) or reoperation (OR=1.04; 95% CI 0.93 to 1.16; p=0.49). One mortality was recorded in the DOAC group within 30 days of admission, and this compared with five in the matched group of patients (p=0.2).ConclusionsDelaying surgery in patients who sustain a hip fracture who are taking a DOAC drug has not been shown to reduce perioperative bleeding or affect their mortality in this study.

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

“…In contrast, our DOAC-using patients did not wait significantly longer for surgery than the non-users. Another study investigated hip fracture patients using DOACs compared to matched controls with a median of only 19 h from admission to surgery [30]; no association between surgical delay and perioperative fall in haemoglobin, transfusion rate or reoperation for DOAC-users was found. As our study did not find increased bleeding-and transfusion-complications among patients using DOAC, early surgical interventions appear safe.…”

“…We need to acknowledge that reoperation due to wound ooze is a late solution to persisting oozing. One earlier study has investigated DOAC-users' risk of reoperation due to wound ooze and found no relation to surgical delay [30]. On the other hand, when studying hip fracture patients not accounting for chronic anticoagulation, surgical delay has been found to be a risk factor for wound infections [28,33].…”

Do anticoagulants affect outcomes of hip fracture surgery? A cross-sectional analysis

“…Its cost has restricted its widespread use. A recent study using audit data from a single hospital reported that hip fracture surgery for patients taking DOAC had a median time to theatre of 19 h [22]. Compared to a matched cohort, there was no difference in perioperative haemoglobin concentration, requirement for transfusion and reoperation suggesting that early surgery is possible even for patients on DOACs [22].…”

“…A recent study using audit data from a single hospital reported that hip fracture surgery for patients taking DOAC had a median time to theatre of 19 h [22]. Compared to a matched cohort, there was no difference in perioperative haemoglobin concentration, requirement for transfusion and reoperation suggesting that early surgery is possible even for patients on DOACs [22]. Our own study reported a median time to theatre of 27 h, which is within the required 36 h to achieve UK Best Practice Tariff for hip fracture management, a payment tariff for hospitals set nationally.…”

Interdisciplinary care of hip fractures.

“…All these drugs will increase risk of perioperative bleeding at the fracture site, but an even greater concern is bleeding related to spinal anesthesia which can cause spinal injury. A recent study showed that perioperative bleeding and 30days mortality were not increased by use of DOAC without delay in surgery [43]. However, it is recommended to stop DOACs at admission and wait for 24-48 hours after last dose has been taken before spinal anesthesia can be given.…”