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

Main Article Content

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


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.

Article Details

Review articles


1. Johansen A, Tsang C, Boulton C, Wakeman R, Moppett I.
Understanding mortalityratesafterhip fracturerepairusing
ASA physical status in the National Hip Fracture Database.
2. Rozenfeld M, Bodas M, Shani M,etal. National study: most
elderly patients benefit from earlier hip fracture surgery
despiteco-morbidity. Injury2020.
3. Pincus D, Ravi B, Wasserstein D,etal. Association between
wait time and 30-day mortality in adults undergoing hip
fracturesurgery. JAMA 2017;318:1994-2003.
4. Pioli G, Bendini C, Giusti A, et al. Surgical delay is a risk
factorof delirium inhip fracture patients with mild-moderate
cognitiveimpairment. Aging Clin Exp Res2019;31:41-7.
5. Sayers A, Whitehouse MR, Berstock JR, Harding KA, Kelly
MB, Chesser TJ. The association between the day of the
week of milestones in the care pathway of patients with hip
fracture and 30-day mortality: findings from a prospective
national registry - The National Hip Fracture Database of
England and Wales. BMC Med 2017;15:62.
6. Yang Z, NiJ,Long Z, Kuang L, Gao Y,Tao S. Iship fracture
surgery safe for patients on antiplatelet drugs and is it
necessary to delay surgery? A systematic review and
meta-analysis. J Orthop Surg Res2020;15:105.
7. HIP ATTACK investigators. Accelerated surgery versus
standard careinhip fracture(HIP ATTACK):aninternational,
randomised,controlled trial.Lancet2020;395:698-708.
8. Ferrari E, Benhamou M, Cerboni P, Marcel B. Coronary
syndromes following aspirin withdrawal: a special risk for
latestent thrombosis. J Am Coll Cardiol2005;45:456-9.
9. Godier A, Garrigue D, Lasne D, et al. Management of
antiplatelet therapy for non-elective invasive procedures or
bleeding complications: Proposalsfrom theFrenchWorking
Group on Perioperative Haemostasis(GIHP)and theFrench
Study Group on Thrombosis and Haemostasis (GFHT), in
collaboration with the French Society for Anaesthesia and
IntensiveCare(SFAR). ArchCardiovasDis2019;112:199-216.
10. Yassa R, Khalfaoui MY, Hujazi I, Sevenoaks H, Dunkow P.
Managementofanticoagulationinhip fractures: A pragmatic
approach. EFORT Open Rev2017;2:394-402.
11. Hindy-François C, Bachelot-Loza C, Le Bonniec B, et al.
Recombinantactivated factor VII doesnot reduce bleeding
in rabbits treated with aspirin and clopidogrel. Thromb
12. BonhommeF,LecompteT, Samama CM, Godier A,Fontana
P. Evaluation of recombinant factor VIIa, tranexamic acid
and desmopressin to reduce prasugrel-related bleeding:
A randomised, placebo-controlled study in a rabbit model.
Eur J Anaesthesiol2018;35:208-14.
13. Luo X, He S,Li Z,Li Q. Quantificationand influencing factors
of perioperative hidden blood loss during intramedullary
fixation for intertrochanteric fractures in the elderly. Arch
Orthop Trauma Surg 2020;140:1339-48.
14. CaiL,WangT,DiL,HuW,WangJ.Comparisonofintramedullary
and extramedullaryfixationofstableintertrochantericfractures
in the elderly: a prospective randomised controlled trial
exploringhiddenperioperative bloodloss.BMCmusculoskelet
disord 2016;17:475.
15. Foss NB, Kehlet H. Hidden blood loss after surgery for hip
fracture. J BoneJoint Surg Br2006;88:1053-9.
16. Ueoka K, Sawaguchi T, Goshima K, Shigemoto K, Iwai S,
Nakanishi A.Theinfluenceof pre-operativeantiplateletand
anticoagulant agents on the outcomes in elderly patients
undergoing early surgery for hip fracture. J Orthop Sci
17. NydickJA,Farrell ED, Marcantonio AJ, Hume EL, Marburger
R, Ostrum RF. The use of clopidogrel (Plavix) in patients
undergoing nonelective orthopaedic surgery. J Orthop
18. Manning BJ, O’Brien N, Aravindan S, Cahill RA, McGreal G,
Redmond HP. The effect of aspirin on blood loss and
transfusion requirements in patients with femoral neck
fractures. Injury2004;35:121-4.
19. Sa-Ngasoongsong P, Kulachote N, Sirisreetreerux N, et al.
Effectofearly surgery inhighsurgical risk geriatric patients
with femoral neck fracture and taking antiplatelet agents.
World J Orthop 2015;6:970-6.
20. Britt RB, Brown JN. Characterizing the severe reactions of
21. Curtis R, Schweitzer A, van Vlymen J. Reversal of warfarin
anticoagulation for urgent surgical procedures. Can J
22. Bhatia M,Talawadekar G, Parihar S, Smith A. Anauditof the
role of vitamin K in the reversal of International Normalised
Ratio (INR) in patients undergoing surgery for hip fracture.
Ann R Coll Surg Engl2010;92:473-6.
23. Tharmarajah P, Pusey J, Keeling D, Willett K. Efficacy of
warfarin reversal in orthopedic trauma surgery patients.
J Orthop Trauma2007;21:26-30.
24. Al-Rashid M, Parker MJ. Anticoagulationmanagement inhip
fracture patientson warfarin. Injury2005;36:1311-5.
25. Grandone E, Ostuni A,Tiscia GL, MarongiuF, Barcellona D.
Managementof patientstaking oralanticoagulants whoneed
urgent surgery for hip fracture. Semin Thromb Hemost
26. Mattisson L, Lapidus LJ, Enocson A. Is fast reversal and
earlysurgery(within24h) in patientson warfarin medication
with trochanteric hip fractures safe? A case-control study.
BMC Musculoskelet Disord 2018;19:203.
27. Siegal D, YudinJ, Kaatz S, DouketisJD,LimW, Spyropoulos
AC. Periprocedural heparin bridging in patients receiving
vitamin K antagonists:systematicreview and meta-analysis
of bleeding and thromboembolic rates. Circulation 2012;
28. Yong JW, Yang LX, Ohene BE, Zhou YJ, Wang ZJ.
Periprocedural heparin bridging in patients receiving oral
anticoagulation:asystematicreview andmeta-analysis. BMC
cardiovascular disorders.2017;17:295.
29. Pollack CV Jr, Reilly PA, van Ryn J, et al. Idarucizumab for
dabigatran reversal - full cohort analysis. N Engl J Med
30. Schermann H, Gurel R, Gold A, et al. Safety of urgent hip
fracture surgery protocol under influence of direct oral
anticoagulation medications. Injury2019;50:398-402.
31. Frenkel Rutenberg T, Velkes S, Vitenberg M,etal. Morbidity
and mortality after fragility hip fracture surgery in patients
receiving vitamin K antagonistsand directoralanticoagulants.
Thromb Res2018;166:106-12.
32. Mullins B, Akehurst H, Slattery D, ChesserT. Should surgery
be delayed in patientstaking directoralanticoagulants who
suffer a hip fracture? A retrospective, case-controlled
observationalstudyata UK major traumacentre. BMJopen
33. Tarrant SM, Catanach MJ, Sarrami M, Clapham M, Attia J,
Balogh ZJ. Direct oral anticoagulants and timing of hip
fracturesurgery. J Clin Med 2020;9-12.
34. Gautier N, Pirson A, Lechat J-P, Van Der Linden P. Impact
of directoralanticoagulant therapyonoperative delay, blood
loss, transfusionand postoperative morbidity mortalityinhip
fracture patient, an observational study. Thromb Res
35. SteffelJ, Verhamme P, PotparaTS,etal.The2018 European
Heart Rhythm Association Practical Guide on the use of
non-vitamin K antagonistoralanticoagulantsin patients with
atrial fibrillation. Eur Heart J2018;39:1330-93.
36. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W,
Leffert LR, Benzon HT. Regional anesthesia in the patient
receiving antithrombotic or thrombolytic therapy: American
Societyof Regional Anesthesiaand PainMedicineevidencebased guidelines (fourth edition). Reg Anesth Pain Med
37. Narouze S, Benzon HT, Provenzano DA,etal. Interventional
spine and pain procedures in patients on antiplatelet and
anticoagulant medications: guidelines from the American
Society of Regional Anesthesia and Pain Medicine, the
European Societyof Regional Anaesthesiaand PainTherapy,
the American Academy of Pain Medicine, the International
Society, and the World Institute of Pain. Reg Anesth Pain
Med 2015;40:182-212.
38. Albaladejo P, Bonhomme F, Blais N, et al. Management of
direct oral anticoagulants in patients undergoing elective
surgeriesand invasive procedures: Updated guidelinesfrom
the French Working Group on Perioperative Hemostasis
(GIHP) - September 2015. Anaesth Crit Care Pain Med
39. DouketisJD, Spyropoulos AC, DuncanJ,etal. Perioperative
management of patients with atrial fibrillation receiving
a direct oral anticoagulant. JAMA Intern Med 2019;179:
40. ViktilKK,LehreI,RanhoffAH,Molden E. Serumconcentrations
and elimination rates of direct-acting oral anticoagulants
(DOACs) in older hip fracture patients hospitalized for
surgery: A pilot study. Drugs Aging 2019;36:65-71.
41. Kim HK, Tantry US, Smith SC, et al. The East Asian
Paradox:an updated position statement on the challenges
to the current antithrombotic strategy in patients with
cardiovascular disease.Thromb Haemost.2020.