hip fractures Dr Linda Xu lindaxuhealthnswgovau Dr Nichola Boyle Prof LeCouteur Concord Repatriation General Hospital NSW Australia Background Hip fracture most costly fracture type based on per fracture basis ID: 933003
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Slide1
Perioperative management of anticoagulated geriatric patients with hip fractures
Dr Linda Xu linda.xu@health.nsw.gov.auDr Nichola Boyle Prof LeCouteurConcord Repatriation General Hospital, NSW Australia
Slide2BackgroundHip fracture most costly fracture type based on “per fracture” basisAccount for 42% of direct cost burden of all fractures in Australia
(Watts 2013)Novel oral anticoagulants first listed on PBS in 2013Rate of fatal bleeding 0.16 per 100 patient years in NOACs compared to 0.32 warfarin (Chai-Adisaksopha 2015)Evidence based anticoagulation management protocols shown to reduce surgical delay in hip fracture
(
Leonidou, 2013;
Ashouri
2011;
Ahmed
2014)
Slide3Hypothesis and aimsPerioperative management of fractured NOF on warfarin vs NOACGuideline released by Australian Society of Thrombosis and Haemostasis, 2014
Use of blood products post surgeryComplications seen post operatively Proportion of patients remaining on anticoagulants at discharge
Slide4Study DesignRetrospective observational study January 2014 to December 2015 750 bed tertiary teaching hospital
Patients ≥ 65 years admitted through ED on warfarin or NOAC Inclusions- Hx of AF and taking warfarin or NOAC on admission notes and discharge summaryExclusion- Anticoagulation for DVT, PE or thromboembolic disease, mechanical valve replacement patients, patients on aspirin/clopidogrel unless concurrently on warfarin/NOAC
Slide5DataBaseline demographics- age, sex, weight (if available), Charlson Age Comorbidity Index, CHADSVASC/HASBLED scoreCoagulation profile, drug assays
Perioperative haemostatic agents and blood productsFracture and surgery typeDelay in surgeryLength of stayComplications
Slide6Results
Slide7Characteristics of warfarin vs NOAC group
Slide8Results Delay in surgery- 10/20 warfarin, 6/11 NOACs3 interhospital transfersNo statistical difference between two groups (p=0.08)
Slide9Pre-operative70% of warfarin patients required vit K20% of warfarin patients received prothrombinex, FFP, pooled platelet, 1 patient received tranexamic acid7/11 NOAC patients had the correct assays/coagulation studies performed
0 NOAC received any haemostatic agents
Slide10Bleeding
Majority of patients continued on warfarin or NOAC on discharge (27/31)
Slide11Length of stay Warfarin13.56.4 days NOAC
22.622.7 days p = 0.02
Slide12Limitations and strengthsSmall number of subjects satisfied criteriaAccuracy of patient records
Australian and New Zealand Hip Fracture Registry (ANZHFR) from late 2015 Not covered- type of surgery and surgical techniques contributing to post-op bleedingStudy prior to 2017 CEC released NOAC guidelines.Dabigatran reversal now available
Slide13ConclusionAbility to reverse anticoagulation differed with no significant difference in time to surgery Only warfarin patients received haemostatic agents, consistent with ASTH guidelines
No difference in blood product requirements post-operativelyLOS was significantly longer in NOAC
Slide14CreditsProject supervisors Dr Nichola Boyle and Prof David LeCouteur, Concord Repatriation General HospitalMegan White, Orthopaedics CNC, Concord Repatriation General Hospital
Slide15Questions?
Slide16ReferenceChai-Adisaksopha C, Hillis C, Isayama T, Lim W, Iorio A, Crowther M. Mortality outcomes in patients receiving direct oral anticoagulants: a systematic review and meta-analysis of randomized controlled trials. Journal of Thrombosis and Haemostasis. 2015; 13(11): 2012–2020
.Watts J, Abimanyi-Ochom J, Sanders K. Osteoporosis costing all Australians. A new burden of disease analysis- 2012 to 2022 [Internet]. Osteoporosis Australia; 2013 [cited August 2016]. Available from: http://www.osteoporosis.org.au/sites/default/files/files/ Burden%20of%20Disease%20Analysis%202012-2022.pdf
.
Leonidou
A, Rallan R, Cox N, Pagkalos J, Luscombe J. Comparison of different warfarin reversal protocols on surgical delay and complication rate in hip fracture patients. Journal of Orthopaedic Surgery. 2013; 21(2): 142-145.
Ashouri F, Al-Jundi W, Patel A, Mangwani J. Management of warfarin anticoagulation in patients with fractured neck of femur. ISRN Haematology. 2011; 2011:1-5. Available from:
http://www.hindawi.com/journals/isrn/2011/294628/
Ahmed I, Khan MA, Nayak V, Mohsen A. An evidence-based warfarin management protocol reduces surgical delay in hip fracture patients. Journal of Orthopaedics and Traumatology. 2014;15(1):21-27
.
Weitz J, Semchuk W, Turpie A, Fisher W, Kong C, Ciaccia A et al. Trends in prescribing oral anticoagulants in Canada, 2008-2014. Clinical Therapeutics. 2015; 37(11): 2506-2514.
Slide17Length of stay
Age
Anticoagulation
Charlson Comorbidity Index
Hip fracture details
Type of fracture
Surgery
Delay in surgery (1 for >48hrs)
Bridging therapy
Ortho length of stay (days)
Disposition
Dicharge on anticoagulation (1/0)
Time to recommencement of anticoag (days)
Others (pressure ulcers, infections, delirium)
87
apixaban
6
left neck of femur
left dynamic hip screw
1
Post op 48hrs
11
Rehab
1
2
Nil
95
apixaban
11
left subcapital neck of femur
Left hip cannulated screws
0
0
NH patient
1
3
bronchopneumonia, AKI
87
dabigatran
7
left subtrochanteric proximal femur
A2FN insertion
1
Heparin pre op till 8hrs pre op. Post op heparin
63
Rehab
1
3
Serous ooze wound, Rx with flucloxacillin IV/PO
89
dabigatran
12
left intertrochanteric femur
left dynamic hip screw
1
N
13
NH patient (home)
0
not commenced
CTB- small acute subdural haematoma, ?brainstem infarct, fluctuating GCS post op but CTB did not show intracranial haemorrhage. EEG showed moderately severe encephalopathy. Given naloxone with improvement. CAP on presentation with rapid AF. Rapid AF post op in recovery.
89
rivaroxaban
7
left interchocanteric femur
lefft dynamic hip screw
0
N
10
Rehab
1
1
83
rivaroxaban
5
right subcapital neck of femur
Right hemiarthroplasty
1
9
NH patient (home)
1
4
Delirium on background of dementia
86
rivaroxaban
4
Right displaced subcapital neck of femur fracture
Right hip hemiarthroplasty
1
0
15
Rehab
1
4
Labile BP due to MSA, hypoactive delirium, mild facial droop with no radiological evidence of CVA (d/c does not say if resolved).
87
rivaroxaban
5
Intertorchanteric fracutre left neck of femur
left hip DHS
0
0
13
Rehab
1
2
92
rivaroxaban
6
left displaced subcapital neck of femur fracture
left hip hemiarthroplasty
0
0
9
NH patient (home)
0
2
urinary retention
67
rivaroxaban
3
left intertrochanteric fracture
left DHS
0
0
15
rehab
1
3
nil
86
rivaroxaban 15mg
5
left intertrochanteric femur frac ture and left distal radius fracture
Left DHS and closed reduction left wrist
1
0
68
new to NH
1
2
Post op delirium and rapid AF, UTI
Slide18Complications Not specific to anticoagulation useInclude infections (chest and urine), AKI, wound, CVA, rapid AF, delirium, BP related, urinary retention, pressure injuries, abnormal LFTs, medication related, decline in mobility, fluid and electrolytes, opiate related
Slide19Time to recommencement of anticoagulation2.61.0 days in warfarin group
1.91.5 days in NOACs (p=0.1)
Slide20Anticoagulation bridging4/20 warfarin patients had postoperative bridging heparin whilst 2/11 did in NOAC group. 2/11 in NOAC