Anticoagulation Before Emergency Hip Arthroplasty
Patients should NOT be anticoagulated before emergency hip arthroplasty due to increased risk of bleeding at the surgical site and wound hematoma. 1
Rationale for Avoiding Preoperative Anticoagulation
- Emergency hip arthroplasty is considered a high bleeding risk procedure, and initiating anticoagulation before surgery would significantly increase perioperative blood loss and complications 1
- The risk of bleeding at the surgical site and wound hematoma is greater with preoperative anticoagulation, which could compromise surgical outcomes 1
- Guidelines specifically recommend starting thromboprophylaxis postoperatively rather than preoperatively for hip arthroplasty to balance bleeding and thrombotic risks 1
Appropriate Timing for Anticoagulation
- Thromboprophylaxis should be initiated postoperatively, with the first dose given at least 12 hours after surgery completion 1
- For patients undergoing hip arthroplasty, low-molecular-weight heparin (LMWH) is preferred over adjusted-dose warfarin when started postoperatively 1
- Direct oral anticoagulants (DOACs) like apixaban should be started 12-24 hours after surgery when hemostasis is achieved 1
Recommended Postoperative Prophylaxis Options
- LMWH is the preferred method of prophylaxis for hip arthroplasty when started postoperatively (Grade 1A evidence) 1
- Adjusted-dose warfarin (INR target 2.5, range 2.0-3.0) is an alternative but more complex to manage (Grade 2A) 1
- Fondaparinux is recommended particularly for hip fracture surgery but should be started postoperatively 1, 2
- Mechanical prophylaxis with intermittent pneumatic compression (IPC) devices or elastic stockings may provide additional efficacy when combined with pharmacological methods (Grade 2C) 1
Duration of Prophylaxis
- Thromboprophylaxis should be continued for a minimum of 10-14 days after hip arthroplasty 1
- Extended prophylaxis for up to 35 days (5 weeks) is recommended for hip arthroplasty patients due to persistent VTE risk that can extend up to 2 months postoperatively 1
- The risk of DVT remains significant (12-37%) even after hospital discharge, supporting the need for extended prophylaxis 1
Special Considerations
- For patients with a history of VTE undergoing hip arthroplasty, a multimodal approach is recommended with postoperative anticoagulation rather than preoperative initiation 3
- Patients should be assessed for bleeding disorders like hemophilia and active liver disease before determining the appropriate thromboprophylaxis strategy 4
- Regional anesthesia (neuraxial) can help limit blood loss during surgery and should be considered as part of the overall strategy 4
Potential Pitfalls
- Initiating anticoagulation before emergency surgery significantly increases the risk of major bleeding complications and may necessitate surgical re-intervention 1
- Preoperative anticoagulation may interfere with the ability to use regional anesthesia techniques, which are beneficial for pain control and limiting blood loss 1
- The fear of VTE should not lead to premature anticoagulation before emergency hip arthroplasty, as proper timing is crucial for balancing thrombotic and bleeding risks 5
By following these evidence-based recommendations, clinicians can effectively prevent venous thromboembolism while minimizing bleeding complications in patients undergoing emergency hip arthroplasty.