What is the risk of alcohol use on thrombosis following emergency hip replacement for femoral neck fracture?

Risk of Alcohol Use in Thrombosis Following Emergency Hip Replacement for Femoral Neck Fracture

Alcohol dependence is a significant risk factor for thrombosis in patients undergoing emergency hip replacement for femoral neck fracture, as these patients are at risk for significant peri-operative morbidity including thromboembolism. 1

Thrombosis Risk in Hip Fracture Patients

• The overall prevalence of venous thromboembolism (VTE) in hip fracture patients is high, with studies showing rates of 18.9-28.0% 2, 3
• Venogram and ventilation/perfusion studies have shown a prevalence of 37% for deep vein thrombosis (DVT) and 6% for pulmonary embolism (PE) in hip fracture patients 1
• Clinical symptoms are only seen in 1-3% of DVTs and 0.5-3% of PEs, making screening important 1
• Many DVTs occur preoperatively (71.7% in one study), indicating that the fracture itself and immobilization are significant risk factors 3

Alcohol Use as a Risk Factor

• Alcohol dependence is common, under-diagnosed, and a risk factor for falls leading to femoral neck fractures 1
• Patients with alcohol dependence are at risk for significant peri-operative morbidity, including thrombotic complications 1
• Initial Bispectral Index (BIS) levels may be abnormally low in alcoholic patients, which can affect anesthetic management and potentially increase thrombosis risk 1

Other Risk Factors for Thrombosis in Hip Fracture Patients

• Multiple fractures (odds ratio 9.418) 2
• Coexisting movement disorders (odds ratio 3.862) 2
• Bed rest for more than 7 days (odds ratio 2.082) 2
• Elevated D-dimer levels (odds ratio 1.019) 2
• Elevated fibrinogen levels (odds ratio 1.345) 2
• Delay in surgery (>48 hours from injury) 4
• Hypercoagulability as measured by thrombelastography 5

Protective Factors Against Thrombosis

• Recent use of antiplatelet drugs (odds ratio 0.424) 2
• Prophylactic anticoagulation (odds ratio 0.503) 2
• Regional anesthesia 1
• Early mobilization 1
• Maintaining adequate hydration 1

Management Recommendations for Thrombosis Prevention

• Fondaparinux or low molecular weight heparins should be prescribed for thromboprophylaxis 1
• Low molecular weight heparin should be administered between 18:00 and 20:00 to minimize bleeding risk related to neuraxial anesthesia during daytime trauma lists 1
• Thromboembolism stockings or intermittent compression devices should be employed intra-operatively 1
• Ensure the patient remains warm and well-hydrated throughout perioperative care 1
• Expedited surgery and early mobilization are recommended to reduce DVT risk 1
• Regional anesthesia techniques may help reduce DVT risk compared to general anesthesia 1

Special Considerations for Patients with Alcohol Dependence

• Patients with alcohol dependence may require additional monitoring during surgery, including BIS monitoring to optimize anesthesia depth 1
• These patients may have altered coagulation profiles and require careful assessment of thrombosis risk 1
• Alcohol withdrawal should be anticipated and managed appropriately to prevent complications that could increase thrombosis risk 1
• Optimized perioperative fluid management is particularly important in these patients to reduce morbidity 1

Pitfalls and Caveats

• Preoperative DVT is common (29.4% in one study) and may persist postoperatively despite prophylaxis 6
• 66.7% of patients diagnosed with DVT postoperatively already had thrombus before surgery 6
• Therapeutic anticoagulation for isolated calf muscular venous thrombosis (ICMVT) prior to surgery may worsen postoperative anemia without reducing the risk of thrombus extension 2
• Careful balance is needed between thromboprophylaxis and bleeding risk, especially when considering neuraxial anesthesia techniques 1