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Preoperative warfarin reversal for early hip fracture surgery
Thomas Steven Moores1, Alastair Beaven, Andrew Edwin Cattell
1Trauma and Orthopaedic Department, University Hospital of North Staffordshire, United Kingdom.
Insights
Low-dose vitamin K effectively reverses warfarin for hip fracture surgery patients within 18 hours. Early surgery improves outcomes, reducing mortality and venous thromboembolism risk.
Area of Science:
- Geriatric Medicine
- Pharmacology
- Trauma Surgery
Background:
- Warfarin is commonly prescribed for conditions like atrial fibrillation and venous thromboembolism.
- Preoperative warfarin reversal is crucial for patients undergoing urgent hip fracture surgery.
- Achieving rapid and safe anticoagulation reversal impacts surgical outcomes.
Purpose of the Study:
- To assess the efficacy and safety of a hospital protocol using low-dose vitamin K for preoperative warfarin reversal.
- To determine the time required for warfarin reversal to achieve a surgical international normalized ratio (INR) threshold.
- To evaluate the impact of early hip fracture surgery on patient morbidity and mortality.
Main Methods:
- Retrospective review of 49 patients (16 male, 33 female) aged 63-93 undergoing hip fracture surgery.
- Administration of low-dose vitamin K and monitoring of international normalized ratio (INR) levels.
- Stratification of patients into low-risk and high-risk (prosthetic heart valve) groups.
Main Results:
- Low-dose vitamin K reversed warfarin in low-risk patients to an INR <1.7 within a mean of 14 hours (range, 0-4 administrations).
- 78% of low-risk patients achieved surgical readiness within 36 hours.
- No venous thromboembolism events occurred within one year; 30-day and one-year mortality rates were 8.2% and 32.6%.
Conclusions:
- The low-dose intravenous vitamin K protocol is a safe and effective method for rapid warfarin reversal.
- Achieving hip fracture surgery within 36 to 48 hours is associated with improved patient morbidity and mortality.
- This protocol facilitates timely surgical intervention for elderly patients on warfarin.
Purpose:
To evaluate our hospital protocol of low-dose vitamin K titration for preoperative warfarin reversal for early hip fracture surgery.
Methods:
Records of 16 men and 33 women aged 63 to 93 (mean, 81) years who were taking warfarin for atrial fibrillation (n=40), venous thromboembolism (n=9), cerebrovascular accident (n=3), and prosthetic heart valve (n=3) and underwent surgery for hip fractures were reviewed. The 3 patients with a prosthetic heart valve were deemed high risk for thromboembolism and the remainder low-risk. The international normalised ratio (INR) of patients was checked on admission and 6 hours after administration of vitamin K; an INR of <1.7 was considered safe for surgery.
Results:
No patient developed venous thromboembolism within one year. The 30-day and one-year mortality was 8.2% and 32.6%, respectively. For the 46 low-risk patients, the mean INR on admission was 2.6 (range, 1.1-4.6) and decreased to <1.7 after a mean of 2.2 (range, 0-4) administrations of 2 mg of vitamin K. Their INR was <1.7 within 18 hours (mean, 14 hours). 78% of patients underwent surgery within 36 hours. In the 22% of patients who did not undergo surgery within 36 hours, the delay was due to insufficient operative time or the patient being medically unfit for surgery. The 3 high-risk patients underwent bridging therapy of low-molecular-weight heparin and received no vitamin K; their mean INR on admission was 3.2 (range, 3.1-3.3) and the mean time to surgery was 5.3 (range, 3-8) days. Two low-risk patients and one high-risk patient died within 5 days of surgery.
Conclusion:
The low-dose intravenous vitamin K protocol is safe and effective in reversing warfarin within 18 hours. Hip fracture surgery within 36 to 48 hours of admission improves morbidity and mortality.
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