What is the preoperative and postoperative anticoagulation management for patients undergoing hip fracture surgery?

Perioperative Anticoagulation Management for Hip Fracture Surgery

For hip fracture patients requiring surgery, anticoagulation should not delay surgery, with specific preoperative interruption intervals based on the type of anticoagulant and postoperative resumption typically 24 hours after surgery. 1

Preoperative Anticoagulation Management

Antiplatelet Medications

• Aspirin

  • May be withheld during inpatient stay unless indicated for unstable angina or recent/frequent transient ischemic attacks 1
  • Surgery should not be delayed due to aspirin therapy 1

• Clopidogrel

  • Should generally not be stopped on admission, especially in patients with drug-eluting coronary stents 1
  • Surgery should proceed without delay 1
  • Expect marginally greater blood loss but no need for prophylactic platelet administration 1

Anticoagulants

• Warfarin

  • Target INR < 2 for surgery and < 1.5 for neuraxial anesthesia 1
  • Small amounts of vitamin K may be used to reverse effects 1
  • Supplemental perioperative anticoagulation with heparins is usually indicated 1
  • Prothrombin complex concentrates can rapidly reverse effects but are rarely indicated 1

• Direct Oral Anticoagulants (DOACs)

  • For urgent hip fracture surgery, anti-factor Xa measurement may be considered 1
  • For patients with normal renal function:
    • Low-to-moderate bleeding risk procedures: interrupt for 1 full day before surgery (30-36 hours) 1
    • High bleeding risk procedures: interrupt for 2 full days before surgery (60-68 hours) 1
  • For dabigatran patients with impaired renal function (CrCl < 50 mL/min): interrupt for 3-4 full days 1
  • Recent evidence suggests early surgery (within 48 hours) may be safe in patients taking DOACs despite theoretical bleeding risk 2

Anesthesia Considerations

• The incidence of vertebral canal hematoma after neuraxial anesthesia is very small (1:118,000) 1
• For patients on anticoagulants/antiplatelets:
  • General anesthesia may be preferred to avoid risk of vertebral canal hematoma 1
  • For some patients, the risk of vertebral canal hematoma may be significantly less than the risk of general anesthesia 1
  • Balance risks and benefits on an individual basis 1

Postoperative Anticoagulation Management

• Warfarin

  • Recommence 24 hours after surgery 1
  • Some departments recommence it later on the day of surgery 1

• Thromboprophylaxis

  • Both preoperative and postoperative initiation of LMWH appear to have similar safety profiles 3
  • Monitor for signs of bleeding complications, including:
    • Back pain with radicular distribution
    • Motor or sensory impairment
    • Altered bowel or bladder function 1

Monitoring

• For patients on fondaparinux:
  • Routine coagulation tests (PT, aPTT) are relatively insensitive measures of activity 4
  • Periodic routine complete blood counts, serum creatinine level, and stool occult blood tests are recommended 4
  • Anti-Factor Xa assay using appropriate calibrator can measure activity 4

Special Considerations

• Delay to surgery beyond 24-48 hours is associated with significant and progressive mortality and morbidity risks 1
• Approximately 30-40% of hip fracture patients are taking anticoagulant/antiplatelet medications preoperatively 1
• Abrupt cessation of antiplatelet/anticoagulant medication can increase risks of cardiac ischemia, stent occlusion, cerebrovascular accident, and limb ischemia 1
• This is particularly important for patients on dual antiplatelet therapy or when treatment is discontinued soon after initiation 1

Potential Complications

• Preoperative use of low-dose aspirin has been associated with increased need for postoperative blood transfusions and higher all-cause mortality during the first year after surgery 5
• Monitor for thrombocytopenia, which can occur with anticoagulant therapy 4
• Watch for signs of expanding hematoma, infection, and neurovascular compromise 6

The management of anticoagulation in hip fracture patients requires balancing the risks of thromboembolism against the risks of perioperative bleeding. Early surgery (within 24-48 hours) is generally recommended even for patients on anticoagulation, with appropriate perioperative management strategies to minimize bleeding risk while maintaining protection against thromboembolism.