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Meinig R, Cornutt D, Jarvis S, Salottolo K, Kelly M, Harrison P, Nentwig M, Morgan S, Nwafo N, McNair P, Banerjee R, Woods B, Bar-Or D. Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions. J Clin Orthop Trauma 2020; 14:45-51. [PMID: 33717896 PMCID: PMC7920139 DOI: 10.1016/j.jcot.2020.09.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear. METHODS This was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery. RESULTS There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery. CONCLUSIONS Partial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.
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Key Words
- AAOS, American Academy of Orthopedic Surgeons
- ANOVA, analysis of variance
- CVA, cerebrovascular accident
- DOAC, direct oral anticoagulants
- DVT, deep vein thrombosis
- FFP, fresh frozen plasma
- Geriatric
- HIPAA, health insurance accountability and assurance act
- HLOS, hospital length of stay
- Hip fracture
- ICD, international classification of diseases
- ICU LOS, intensive care unit length of stay
- INR, international normalized ratio
- ION, Injury Outcomes Network
- IQR, interquartile range
- IV, intravenous
- MI, myocardial infarction
- PCC, prothrombin complex concentrates
- PE, pulmonary embolism
- Reversal
- SD, standard deviation
- TQIP, Trauma Quality Improvement Program
- Trauma
- Warfarin
- aPCC, activated prothrombin complex concentrates
- mL, milliliters
- pRBC, packed red blood cells
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Affiliation(s)
- Richard Meinig
- Orthopedic Surgery and Trauma, Penrose Hospital, 1263 Lake Plaza Dr, Colorado Springs, CO, 80906, USA
| | - David Cornutt
- Emergency Medicine, Regional West Medical Center, 4021 Avenue B, Scottsbluff, NE, 69361, USA
| | - Stephanie Jarvis
- Injury Outcomes Network (ION) Research, 501 E. Hampden Ave, Englewood, CO, 80113, USA
| | - Kristin Salottolo
- Injury Outcomes Network (ION) Research, 501 E. Hampden Ave, Englewood, CO, 80113, USA
| | - Michael Kelly
- Orthopedic Surgery and Trauma, Penrose Hospital, 1263 Lake Plaza Dr, Colorado Springs, CO, 80906, USA
| | - Paul Harrison
- General, Trauma, & Orthopedic Surgery, Wesley Medical Center, 3242 E. Murdock Street, Wichita, KS, 67208, USA
| | - Michelle Nentwig
- General, Trauma, & Orthopedic Surgery, Wesley Medical Center, 3242 E. Murdock Street, Wichita, KS, 67208, USA
| | - Steven Morgan
- Orthopedic Surgery, Internal Medicine, Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - Nnamdi Nwafo
- Orthopedic Surgery, Internal Medicine, Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - Patrick McNair
- Orthopedic Sports Medicine and Trauma, St. Anthony Hospital, 11600 West 2nd Plaza, Lakewood, CO, 80228, USA
| | - Rahul Banerjee
- Orthopaedic Trauma, Medical City Plano, 1600 Coit Rd Suite 104, Plano, TX, 75075, USA
| | - Bradley Woods
- General Surgery, Research Medical Center, 2316 East Meyer Boulevard, Kansas City, MO, 64132, USA
| | - David Bar-Or
- Injury Outcomes Network (ION) Research, 501 E. Hampden Ave, Englewood, CO, 80113, USA
- Corresponding author. Injury Outcomes Network (ION) Research, 501 E Hampden Ave, Englewood, CO, 80113, USA.
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Meinig R, Jarvis S, Orlando A, Nwafo N, Banerjee R, McNair P, Woods B, Harrison P, Nentwig M, Kelly M, Smith W, Bar-Or D. Is anticoagulation reversal necessary prior to surgical treatment of geriatric hip fractures? J Clin Orthop Trauma 2020; 11:S93-S99. [PMID: 31992926 PMCID: PMC6977537 DOI: 10.1016/j.jcot.2019.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Hip fracture surgery in geriatric patients on anticoagulants may increase the risk for blood loss. Anticoagulation reversal may lower these risks; however, data on blood loss and transfusions are limited. The study purpose was to compare outcomes between hip fracture patients 1) not on anticoagulants 2) whose anticoagulants were reversed, and 3) whose anticoagulants were not reversed. METHODS This four-year retrospective cohort study at six Level 1 Trauma Centers enrolled geriatric patients (≥65) with isolated hip fractures. The primary outcome was total hospital blood loss (ml). Secondary outcomes: hospital length of stay (HLOS) and volume of packed red blood cells (pRBC) transfusions (ml). Statistical analyses included: Fisher's, chi-squared, Kruskal-Wallis, linear mixed-effect and logistic regression. Bonferroni adjusted alpha = 0.025. RESULTS Of the 459 patients, 189 (41%) were not on anticoagulants, 186 (41%) were reversed, and 84 (18%) were not reversed. The LS mean (SE) blood loss was 134 ml (12) for not reversed patients and 159 (17) for reversed patients; no significant difference compared to those not on anticoagulants [138 (12)], p-diff = 0.14 and 0.83, respectively. The LS mean (SE) HLOS was significantly longer for the reversed patients, 7.7 (0.4) days, when compared to those not on anticoagulants, 6.8 (0.4), p = 0.02, and when compared to those not reversed, 6.3 (0.6), p = 0.01. There was no significant difference in pRBC transfusions. CONCLUSION Not reversing anticoagulants for geriatric hip fractures was not associated with increased volume of blood loss or transfusions when compared to those reversed. Delayed surgery for anticoagulant reversal may be unnecessary and contributing to an increased HLOS.
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Affiliation(s)
- Rick Meinig
- Orthopedic Trauma, Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO, 80907, USA
| | - Stephanie Jarvis
- Trauma Department, ION Research, 383 Corona St. #319, Denver, CO, 80218, USA
| | - Alessandro Orlando
- Trauma Department, ION Research, 383 Corona St. #319, Denver, CO, 80218, USA
| | - Nnamdi Nwafo
- Internal Medicine, Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - Rahul Banerjee
- Orthopedic Surgery, Medical City Plano, 3901 West 15th Street, Plano, TX, 75075, USA
| | - Patrick McNair
- Orthopedic Trauma, St. Anthony’s Hospital, 11600 West 2nd Place, Lakewood, CO, 80228, USA
| | - Bradley Woods
- Surgery Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO, 64132, USA
| | - Paul Harrison
- Trauma Surgery, Wesley Medical Center, 550 N. Hillside St., Wichita, KS, 67214, USA
| | - Michelle Nentwig
- Orthopedic Surgery, Wesley Medical Center, 550 N. Hillside St., Wichita, KS, 67214, USA
| | - Michael Kelly
- Orthopedic Trauma, Penrose Hospital, 2222 North Nevada Ave., Colorado Springs, CO, 80907, USA
| | - Wade Smith
- Orthopedic Trauma, Swedish Medical Center, 501 E Hampden Ave., Englewood, CO, 80113, USA
| | - David Bar-Or
- Trauma Department, ION Research, 383 Corona St. #319, Denver, CO, 80218, USA
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