Key result
Implementing a VKA-reversal protocol for patients with hip fracture significantly reduced time to surgery by a mean of 45.31 hours compared to pre-protocol management, without increasing bleeding risk.
Why the study?
Perioperative management of patients with hip fracture receiving oral anticoagulants requires balancing risks of surgical delay against perioperative hemostasis.
Do expedited-surgery protocols improve time to surgery and perioperative outcomes in anticoagulant-treated patients with hip fracture?
Meta-Analysis (n=3,821)
Do expedited-surgery protocols improve time to surgery and perioperative outcomes in anticoagulant-treated patients with hip fracture?
Implementing expedited-surgery protocols for hip fracture in patients on oral anticoagulants safely reduces time to surgery without increasing mortality, despite a small increase in transfusion risk for DOAC users.
Answers are grounded in this paper and cite their sources.
Expedited protocols may safely shorten surgical delay in anticoagulated hip fracture patients; reinforces evidence for protocol implementation.
BACKGROUND: Perioperative management of patients with hip fracture patients receiving oral anticoagulants requires navigating the risks associated with surgical delay and perioperative hemostasis. The aim of this systematic review and meta-analysis was to evaluate the effect of expedited-surgery protocols on time to surgery and perioperative outcomes in anticoagulant-treated patients with hip fracture. METHODS: We searched MEDLINE, Embase and CENTRAL from inception to May 5, 2020, to identify English-language studies reporting outcomes after expedited hip fracture surgery in patients receiving vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) before hospital admission. We performed a meta-analysis using Mantel-Haenszel weighting for dichotomous variables and inverse variance weighting for continuous variables. RESULTS: Among the 4253 citations identified, 14 studies were included. In the 6 studies eligible for meta-analysis, compared to hip fracture surgery before implementation of a VKA-reversal protocol, surgery after implementation of such a protocol was associated with a significant reduction in time to surgery (mean difference 45.31 h, 95% confidence interval [CI] 15.81 h to 74.80 h). Expedited surgery (within 48 h) in patients who received DOACs preoperatively was not associated with increased surgical duration (mean difference -7.29 min, 95% CI -22.5 min to 7.95 min) or 30-day mortality (odds ratio [OR] 1.30, 95% CI 0.49 to 3.89) compared to patients who did not receive anticoagulants (control patients). However, expedited surgery in DOAC-treated patients was associated with an increased blood transfusion risk compared to control patients (OR 0.58, 95% CI 0.36 to 0.96). CONCLUSION: Implementing a VKA-reversal protocol for patients with hip fracture is effective in decreasing time to surgery, without an increased bleeding risk. Performing hip fracture surgery within 48 hours in DOAC-treated patients is also safe, with a small increase in blood transfusion risk.
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You et al. (2023) conducted a meta-analysis in Hip fracture in anticoagulant-treated patients (n=3,821). Expedited-surgery protocols (VKA-reversal or surgery within 48 hours) vs. Standard care (before protocol implementation or no anticoagulants) was evaluated on Time to surgery (MD 45.31, 95% CI 15.81 to 74.80, p=0.003). Implementing a VKA-reversal protocol for patients with hip fracture significantly reduced time to surgery by a mean of 45.31 hours compared to pre-protocol management, without increasing bleeding risk.
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