Skip to main content

Advertisement

SpringerLink
Log in

Anticoagulation Management in Geriatric Orthopedic Trauma Patients

  • Geriatric Orthopedics (C Quatman and C Quatman-Yates, Section Editors)
  • Published:
Current Geriatrics Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This article will review the perioperative management of geriatric patients on anticoagulants who present for non-elective orthopedic surgery.

Recent Findings

Our understanding of best practices in perioperative anticoagulation management has advanced significantly over the last 5 years. More patients are presenting for surgery on direct oral anticoagulants which require a different approach than the vitamin K antagonist, warfarin. We have come to better appreciate the importance of time to the operating room on outcomes, specifically in hip fracture surgery. Regional anesthesia now has standardized guidelines for preprocedure anticoagulation interruption. Prothrombin complex concentrate has increasing acceptance for warfarin reversal preoperatively. Reversal agents are now available for the direct oral anticoagulants but are not recommended for standard use preprocedure. And there has been a shift away from routine use of bridging anticoagulation periprocedure.

Summary

A team-based approach with input from the surgical, anesthesia, and internal medicine or geriatric team preoperatively is critical to the management of perioperative anticoagulation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Peterson BE, Jiwanlal A, Della Rocca GJ, Crist BD. Orthopedic trauma and aging: it isn’t just about mortality. Geriatric Orthop Surg Rehab. 2015;6(1):33–6.

    Article  Google Scholar 

  2. Ang D, Kurek S, McKenney M, Norwood S, Kimbrell B, Barquist E, et al. Outcomes of geriatric trauma patients on preinjury anticoagulation: a multicenter study. Am Surg. 2017;83:527–35.

    Article  Google Scholar 

  3. Dossett LA, Riesel JN, Griffin MR, Cotton BA. Prevalence and implications of preinjury warfarin use: an analysis of the National Trauma Databank. Arch Surg. 2011;146:565–70.

    Article  Google Scholar 

  4. Caruso, G, Andreotti M, Tonon F, Corradi N, Rizzato D, Valentini A, Valpiani G, Massari L. The impact of warfarin on operative delay and 1-year mortality in elderly patients with hip fracture: a retrospective observational study. J Orthop Surg Res. 2019;14(169). https://doi.org/10.1186/s13018-019-1199-5.

  5. Pincus D, Bheeshma R, Wasserstein D, Huang A, Paterson JM, Nathens AB, et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA. 2017;318(20):1994–2003.

    Article  Google Scholar 

  6. Morrissey N, Iliopoulos E, Osmani AW, Newman K. Neck of femur fractures in the elderly: does every hour to surgery count. Injury. Int J Care Injured. 48:1155–8.

  7. Kim JL, Park JH, Han SB, Cho IY, Jang KM. Allogenic blood transfusion is a significant risk factor for surgical site infection following total hip and knee arthroplasty: a meta-analysis.

  8. Parvizi J, Azzam K, Rothman RH. Deep venous thrombosis prophylaxis for total joint arthroplasty: American Academy of Orthopaedic Surgeons guidelines. J Arthroplast. 2008;23(7 Suppl):2–5.

    Article  Google Scholar 

  9. Wellisz T. Management of bone bleeding during surgery and its impact on the incidence of post-operative osteomyelitis, osteomyelitis. In: Baptista, MS, Tardivo JP (eds) IntechOpen. 2012. https://doi.org/10.5772/31623

  10. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy. American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (fourth edition). Reg Anesth Pain Med. 2018;43:263–309.

    Article  Google Scholar 

  11. Horlocker TT, Wedel DJ. Antcoagulation and neuraxial block: historical perspective, anesthetic implications, and risk management. Reg Anesth Pain Med. 1998;23:129–34.

    CAS  PubMed  Google Scholar 

  12. ASRA (2018) ASRA Coags 2.1 [Mobile application software]. Retrieved from http://itunes.apple.com.

  13. Connolly SJ, Ezekowitz MD, Yusuf S, et al. RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(27):1139–51.

    Article  CAS  Google Scholar 

  14. Patel MR, Mahaffey KW, Garg J, et al. ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883–91.

    Article  CAS  Google Scholar 

  15. Granger CB, Alexander JH, McMurray JJV, et al. ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981–92.

    Article  CAS  Google Scholar 

  16. Anderson M, Hassell K, Trujillo T, Wolfe B. When patients on target-specific oral anticoagulants need surgery. Cleve Clin J Med. 2014;81:629–39.

    Article  Google Scholar 

  17. Pabinger, I, Brenner B, Kalina U, Knaub S, Nagy A, Ostermann H. Prothrombin complex concentrate (Beriplex P/N) for emergency anticoagulation reversal: a prospective multinational clinical trial. J Thromb Haemost. 2008; 6 (4):XXXX.

  18. Burk DR, Smith JL, Wild J. Prothrombin complex concentrates: an alternative to fresh frozen plasma. Orthopedics. 2017;40(2):e367–9.

    Article  Google Scholar 

  19. Levy JH, Douketis J, Steiner T, Goldstein JN, Milling TJ. Prothrombin complex concentrates for perioperative vitamin K antagonist and non-vitamin K anticoagulant reversal. Anesthesiology. 2018;129(6):1171–84.

    Article  CAS  Google Scholar 

  20. Tao J, Bukanova EN, Akhtar S. Safety of 4-factor prothrombin complex concentrate (4F-PCC) for emergent reversal of factor Xa inhibitors. J Intensive Care. 2018;6:34.

    Article  Google Scholar 

  21. Schulman S, Gross PL, Ritchie B, Nahirniak S, Lin Y, Lieberman L, et al. Prothrombin complex concentrate for major bleeding on factor Xa inhibitors: a prospective cohort study. Thromb Haemost. 2018;118(5):842–51.

    Article  Google Scholar 

  22. Kim BH, Lee S, Yoo B, Lee WY, Lim Y, Kim MC, et al. Risk factors associated with outcomes of hip fracture surgery in elderly patients. Korean J Anaesthesiol. 2015;68(6):561–7.

    Article  Google Scholar 

  23. Kilci O, Un C, Sacan O, Gamli M, Baskan S, Baydar M, et al. Postoperative mortality after hip gracture surgery: a 3 years follow up. PLoS One. 2016;11(10):e0162097.

    Article  Google Scholar 

  24. Douketis JD, Spyropoulos AC, Kaatz SO, Becker RC, Caprini JA, Garcia DA, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373:823–33.

    Article  CAS  Google Scholar 

  25. Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis. 9th edition: American College of Chest physicians evidence-based clinical practice guidelines. Chest. 2012;141:e326S–50S.

    Article  CAS  Google Scholar 

  26. Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e419S–94S.

    Article  CAS  Google Scholar 

  27. Kaufman JA, Kinney TB, Streiff MB, Sing RF, Proctor MC, Becker D, et al. Guidelines for the use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology multidisciplinary consensus conference. J Vasc Interv Radiol. 2006;17:449–59.

    Article  Google Scholar 

  28. Caplin DM, Nikolic B, Kalva SP, Ganguli S, Saad WE, Zuckerman DA, et al. Quality improvement guidelines for the performance of inferior vena cava filter placement for the prevention of pulmonary embolism. J Vasc Interv Radiol. 2011;22:1499–506.

    PubMed  Google Scholar 

  29. Weinberg I, Abtahian F, Debiasi R, et al. Effect of delayed inferior vena cava filter retrieval after early initiation of anticoagulation. Am J Cardiol. 2014;113:389–94.

    Article  Google Scholar 

  30. Schulman S, Beyth RJ, Kearon C, Levine MN. Hemorrhagic complications of anticoagulant and thrombolytic treatment: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):257S–98S.

    Article  CAS  Google Scholar 

  31. Patti G, Lucerna M, De Caterina R, et al. Thromboembolic risk, bleeding outcomes and effect of different antithrombotic strategies in very elderly patients with atrial fibrillation: a sub- analysis from the PREFER in AF. Heart Assoc. 2017;e005657. https://doi.org/10.1161/JAHA.117.005657

Download references

Author information

Authors and Affiliations

  1. Hospitalist Service, Yale New Haven Hospital, 20 York Street, New Haven, CT, 06510, USA

    Jensa C. Morris

  2. Department of Orthopaedics & Rehabilitation, Yale University, New Haven, USA

    Mary I. O’Connor

Authors
  1. Jensa C. Morris
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mary I. O’Connor
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jensa C. Morris.

Ethics declarations

Conflict of Interest

The authors have no financial conflicts of interest to disclose.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Geriatric Orthopedics

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Morris, J.C., O’Connor, M.I. Anticoagulation Management in Geriatric Orthopedic Trauma Patients. Curr Geri Rep 9, 288–295 (2020). https://doi.org/10.1007/s13670-020-00345-3

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13670-020-00345-3

Keywords

Search

Navigation