Anticoagulation management in hip fracture patients on warfarin

The management of patients admitted with a fracture requiring surgery who are taking warfarin anticoagulation is unclear. We examined the anticoagulation management for 33 hip fracture patients on warfarin at the time of admission. Hospital course and complications were recorded on all patients. The mean INR on admission was 3.2 and prior to surgery 2.2. Eight patients (24%) had percutaneous cancellous screws for an intracapsular fracture regardless of the admission INR. In 21 (64%) patients, surgery was delayed whilst the INR came down, with an average delay of 72 h from admission to surgery. No specific treatment to lower the INR, other than wait and watch policy adopted in 11 (33%) of these patients. Pharmacological methods used to reduce the INR were fresh frozen plasma in nine cases, and intravenous Vitamin K in four patients. One patient died from post-operative haematemesis and three died from medical complications unrelated to the warfarin therapy. There were no wound haematomas or other bleeding complications. Delaying surgery whilst waiting for the INR to fall to acceptable levels may result in significant delays to surgery and we would recommend a more aggressive policy to enable earlier surgery.