What is the safe time to surgically fix the left hip fracture in an elderly female patient with a severe cardiac history, impaired renal function, and currently on Eliquis (apixaban), who last took the medication this morning?

Safe Timing for Hip Fracture Surgery in Patient on Eliquis with Renal Impairment

For this elderly patient with severe cardiac history, poor kidney function, and last Eliquis dose this morning, surgery can reasonably proceed within 24-48 hours from the last dose, with the specific timing determined by apixaban level if available (target <50 ng/mL) or by waiting approximately 48 hours given her renal impairment. 1

Urgency Classification and Timing Framework

Hip fracture is classified as urgent surgery requiring ideally surgical repair within 24 hours, as delays beyond 24-48 hours significantly increase mortality and morbidity. 1

Decision Algorithm Based on Apixaban Levels (If Available)

If apixaban level testing is available:

• Level <50 ng/mL: Proceed to surgery within 6-8 hours 1
• Level 50-100 ng/mL: Defer surgery for 20-24 hours to allow level to decrease to <50 ng/mL 1
• Level ≥50 ng/mL: Consider reversal with andexanet alfa to allow surgery within 24 hours 1

Decision Algorithm Without Apixaban Level Testing

If apixaban levels are unavailable (most common scenario):

Given she took Eliquis this morning and has poor kidney function, the half-life of apixaban is prolonged in elderly patients with renal impairment. 1, 2

Two reasonable options exist:

1. Wait 48 hours from last dose (passive elimination approach) - This allows sufficient time for drug clearance given her renal impairment, avoiding reversal agent costs and risks 1

2. Reversal with andexanet alfa to proceed within 24 hours - This is reasonable if the time of last dose is unknown or to meet the 24-hour surgical target, particularly given her severe cardiac history where surgical delay poses significant thrombotic risk 1

Critical Considerations for Renal Impairment

The patient's poor kidney function significantly impacts timing:

• Apixaban clearance is reduced by approximately 27% in patients with low body weight and renal impairment 3
• Standard discontinuation times (24 hours for normal renal function) must be extended to 48-72 hours in patients with creatinine clearance <30 mL/min 1, 4
• In elderly patients requiring emergency surgery, apixaban half-life can be prolonged, necessitating longer waiting periods 1

Balancing Competing Risks

The decision must weigh four critical risks:

Risk of Surgical Delay

• Delay beyond 24-48 hours progressively increases mortality and morbidity from immobility complications (pneumonia, pressure ulcers, delirium) 1
• In 2018, approximately 3% of hip fracture patients in England/Wales were delayed >36 hours due to DOAC therapy, with virtually all DOAC patients experiencing this delay 1

Risk of Bleeding

• Continuing anticoagulation or operating with residual drug effect increases perioperative transfusion risk but does not increase mortality 1
• Hip fracture surgery can reasonably be performed <36 hours from last DOAC dose based on international consensus 5

Risk of Thrombosis from Abrupt Cessation

• Her severe cardiac history places her at high risk for cardiac ischemia, stent occlusion, and cerebrovascular events if anticoagulation is abruptly stopped 1, 6
• Premature discontinuation without adequate alternative anticoagulation increases thrombotic event risk 6

Risk of Spinal Hematoma (If Neuraxial Anesthesia Planned)

• The incidence of vertebral canal hematoma in hip fracture patients is extremely low (1:118,000 in general practice, likely even lower in hip fracture population) 1
• General anesthesia should be strongly considered for this patient to avoid spinal hematoma risk while on anticoagulation 1

Anesthetic Approach

Given her anticoagulation status:

• Favor general anesthesia with invasive blood pressure monitoring over neuraxial blockade 1
• If neuraxial anesthesia is considered essential, apixaban must be discontinued ≥48 hours (extend to 72-96 hours given her renal impairment) 4, 6
• Peripheral nerve blocks for analgesia can reasonably be performed even with recent DOAC administration 5

Postoperative Anticoagulation Resumption

Restart apixaban 24-48 hours after surgery once adequate hemostasis is confirmed, considering blood loss and hemoglobin levels. 4, 5

• Earlier resumption (<48 hours) is supported by international consensus to minimize thrombotic risk in high-risk cardiac patients 5
• Do not use bridging anticoagulation with heparin, as this increases bleeding risk without reducing thrombotic events 4

Common Pitfalls to Avoid

• Unnecessarily prolonged delay waiting for "complete clearance" - this increases mortality risk from surgical delay 1
• Failing to account for renal function when determining timing - standard 24-hour windows do not apply with impaired kidney function 1, 4
• Ordering echocardiography that delays surgery - "awaiting echocardiography" is an unacceptable reason to delay hip fracture surgery 1
• Using bridging anticoagulation perioperatively - this is not recommended and increases bleeding risk 4
• Attempting spinal anesthesia without adequate drug clearance time - favor general anesthesia in this scenario 1