Management of patients with hip fracture receiving anticoagulation: What are we doing in Canada?

Background:

Direct oral anticoagulants (DOACs) are rapidly replacing warfarin for therapeutic anticoagulation; however, many DOACs are irreversible and may complicate bleeding in emergent situations such as hip fracture. In this setting, there is a lack of clear guidelines for the timing of surgery. The purpose of this study was to evaluate the current practices of Canadian orthopedic surgeons who manage patients with hip fracture receiving anticoagulation.

Methods:

In January–March 2018, we administered a purpose-specific cross-sectional survey to all currently practising orthopedic surgeons in Canada who had performed hip fracture surgery in 2017. The survey evaluated approaches to decision-making and timing of surgery in patients with hip fracture receiving anticoagulation.

Results:

A total of 280 surgeons representing a mix of academic and community practice, seniority and fellowship training responded. Nearly one-quarter of respondents (66 [23.4%]) were members of the Canadian Orthopaedic Trauma Society (COTS). Almost three-quarters (206 [73.6%]) felt that adequate clinical guidelines for patients with hip fracture receiving anticoagulation did not exist, and 177 (61.9%) indicated that anesthesiology or internal medicine had a greater influence on the timing of surgery than the attending surgeon. A total of 117/273 respondents (42.9%) indicated that patients taking warfarin should have immediate surgery (with or without reversal), compared to 63/270 (23.3%) for patients taking a DOAC (p < 0.001). Members of COTS were more likely than nonmembers to advocate for immediate surgery in all patients (p < 0.05).

Conclusion:

There is wide variability in Canada in the management of patients with hip fracture receiving anticoagulation. Improved multidisciplinary communication, prospectively evaluated treatment guidelines and focus on knowledge translation may add clarity to this issue. Level of evidence: IV.

Septicemic pasteurellosis causing peracute death and necrotizing myositis in a beef heifer calf (Bos taurus) in Alberta, Canada

Septicemic pasteurellosis is an acute and fatal bacterial disease of cattle and wild ungulates caused by certain serotypes of Pasteurella multocida. Here we report a single case of septicemic pasteurellosis in a 6-month-old, Red Angus heifer from a cow-calf operation in Alberta, Canada. Postmortem examination revealed necrotizing and hemorrhagic myositis, fibrinous pericarditis and multisystemic bacterial emboli. Pasteurella multocida was isolated from muscle in pure culture, and the capsular antigen group was identified as serogroup B using polymerase chain reaction. To the best of our knowledge, this is the first reported case of septicemic pasteurellosis in beef cattle in Canada. Key clinical message: Veterinary practitioners and diagnosticians should include septicemic pasteurellosis on their list of differential diagnoses when they encounter similar presentations of peracute death and severe necrotizing myositis in cattle in Canada.