Siriraj Multidisciplinary Consensus on Pre-, Intra- and Postoperative Management of Anticoagulants and Antiplatelets in Fragility Hip Fracture Surgery

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Suwimon Tangwiwat
Mingkwan Wongyingsinn
Varalak Srinonprasert
Thananya Boonyasirinant
Unchana Sura-amonrattana
Suree Sompradeekul
Theerawoot Tharmviboonsri
Direk Tantigate
Nttawut Sermsathanasawadi
Vutthipong Sanphasitvong
Bundarika Suwanawiboon

Abstract

Hip fracture in older patients is urgent and challenging for the multidisciplinary care team due to multiple comorbidities. In-hospital mortality has been reported higher in non-surgical patients than in surgical patients. Earlier hip fracture surgery within 48 hours was found to be beneficial. These advantages include a significant decrease in in-hospital, 30-days and 1-year mortality, delirium, and shorter hospital stays. Among patients with a hip fracture, accelerated surgery within 6 hours did not show significantly lower risk of mortality or composite major complications compared to surgery within 24 hours. The use of anticoagulants or antiplatelets in hip fracture patients may be the cause of delayed surgery. The aim of this recommendation is to provide the practical management of fragility hip fracture surgery for patients receiving anticoagulants and antiplatelets. We suggest treatment protocols based on the available scientific evidence and consensus from multi-specialties. Our conclusions are: surgery should not be delayed in patients on aspirin, clopidogrel, ticagrelor or prasugrel. Spinal anesthesia should be avoided in patients who take antiplatelets except aspirin. Platelet transfusion is indicated only in uncontrollable bleeding situation. Warfarin can be reversed effectively by using 2 to 5 mg of Vitamin K intravenously, and preoperative International Normalised Ratio (INR) target should be less than 1.5. Elderly hip fracture surgery should be performed within 48 hours after discontinuation of direct oral anticoagulants (DOAC) in normal renal function patient. The choice of anesthesia depends on the last dose of DOAC until surgery and renal function.

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