Key result
Patients on DOACs undergoing emergency hip fracture surgery had significantly higher estimated blood loss (500 ml vs 330 ml; P=0.0115) and intra-operative transfusion risk (RR 3.43) than controls.
Why the study?
Many geriatric patients requiring emergency hip fracture surgery receive DOACs, leading to surgical delays beyond 48 hours over concerns of increased perioperative blood loss.
Does early hip fracture surgery (within 24 hours of last DOAC dose) with tranexamic acid administration increase peri-operative blood loss and transfusion requirements compared to non-anticoagulated patients?
Observational (n=131)
Does early hip fracture surgery (within 24 hours of last DOAC dose) with tranexamic acid administration increase peri-operative blood loss and transfusion requirements compared to non-anticoagulated patients?
Mean Difference: 170 (95% CI 38.48–299.16)
Absolute Event Rate: 500% vs 330%
p-value: p=0.0115
Early hip fracture surgery within 24 hours of the last DOAC dose with tranexamic acid administration is safe and avoids surgical delays, despite a modest but manageable increase in blood loss and transfusion requirements.
May support early surgery protocols for hip fractures on DOACs; hypothesis-generating observational data requiring RCT confirmation.
Background: Many geriatric patients presenting for emergency hip fracture surgery are on direct oral anticoagulants (DOACs) most of which are not easily reversible. A safe policy was required to reduce delays to surgery. Prior to institution of our hospital's protocol in January 2021, most of these patients had surgery after 48 h following the last dose of DOAC due to concerns about increased perioperative blood loss. Methods: This was a prospective closed loop audit of the protocol-surgery within 24 h from last dose of DOAC (if creatinine clearance >50 ml/min) with administration of 1-g of tranexamic acid at anesthesia induction. 131 eligible patients (DOAC, n = 22; no anticoagulation, n = 109) between January-June 2021 who had emergency hip fracture surgery were identified. Primary outcome measures were peri-operative blood loss, transfusion requirements and policy compliance. Secondary outcome measures were 30-day mortality, thrombotic complications and wound bleeding. Results: Compliance with surgical timing and tranexamic acid administration were 55% and 81% respectively after the second audit cycle. The mean estimated blood loss (EBL) in the DOAC group versus the non-anticoagulated control group was 500 ml and 330 ml respectively. The difference between these groups was statistically significant at an alpha level of 5% (P = 0.0115, 95% CI 38.48-299.16). The difference for intra-operative (RR 3.43; 95% CI 1.68-7.01) and post-operative blood transfusion (RR 2.10; 95% CI 1.23-3.58) for the 2 groups was also statistically significant. However, there was no case of massive blood transfusion in both groups. The DOAC group had a lower risk for 30-day mortality (RR 0.71; 95% CI 0.09-5.46). There was no major thrombotic complication in the DOAC group. Conclusion: This audit has shown that this protocol is safe although clinicians should anticipate some degree of increased intra-operative blood loss. We will recommend continuation of this policy with sustained safety monitoring in order to reduce delays to surgery.
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Anazor et al. (2022) conducted an observational in Emergency hip fracture surgery (n=131). Direct oral anticoagulants (DOACs) vs. No anticoagulation was evaluated on Peri-operative blood loss (95% CI 38.48-299.16, p=0.0115). Patients on DOACs undergoing emergency hip fracture surgery had significantly higher estimated blood loss (500 ml vs 330 ml; P=0.0115) and intra-operative transfusion risk (RR 3.43) than controls.
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