Role of DOAC plasma concentration on perioperative blood loss and transfusion requirements in patients with hip fractures.
DOAC
DOAC plasma levels
Hip fracture
Perioperative blood loss
RBC transfusion
Journal
European journal of trauma and emergency surgery : official publication of the European Trauma Society
ISSN: 1863-9941
Titre abrégé: Eur J Trauma Emerg Surg
Pays: Germany
ID NLM: 101313350
Informations de publication
Date de publication:
Feb 2023
Feb 2023
Historique:
received:
04
04
2022
accepted:
30
06
2022
pubmed:
17
7
2022
medline:
16
2
2023
entrez:
16
7
2022
Statut:
ppublish
Résumé
There is an ever-increasing number of hip fracture (HF) patients on direct oral anticoagulants (DOAC). The impact of DOAC plasma level prior to HF surgery on perioperative blood loss and transfusion requirements has not been investigated so far. In this retrospective study of HF patients on DOACs admitted to the AUVA Trauma Center Salzburg between February 2015 and December 2021. DOAC plasma levels were analysed prior to surgery. Patients were categorized into four DOAC groups: Group A < 30 ng/mL, Group B 30-49 ng/mL, Group C 50-79 ng/mL, and Group D ≥ 80 ng/mL. Haemoglobin concentration was measured upon admission, prior to surgery, after ICU/IMC admission, and on day 1 and 2 post-surgery. Difference in the blood loss via drains, transfusion requirements and time to surgery were compared. A total of 155 subjects fulfilled the predefined inclusion criteria. The median age of the predominantly female patients was 86 (80-90) years. Haemoglobin concentration in Group D was lower upon admissions but did not reach statistical significance. The decrease in haemoglobin concentration over the entire observation time was comparable between groups. Blood transfusion requirements were significantly higher in Group D compared to Group A and B (p = 0.0043). Time to surgery, intra- and postoperative blood loss via drains were not different among groups. No strong association between the DOAC plasma levels and perioperative blood loss was detected. Higher transfusion rates in patients with DOAC levels ≥ 80 ng/mL were primarily related to lower admission haemoglobin levels. DOAC concentration measurement is feasible and expedites time to surgery.
Sections du résumé
BACKGROUND
BACKGROUND
There is an ever-increasing number of hip fracture (HF) patients on direct oral anticoagulants (DOAC). The impact of DOAC plasma level prior to HF surgery on perioperative blood loss and transfusion requirements has not been investigated so far.
MATERIALS AND METHODS
METHODS
In this retrospective study of HF patients on DOACs admitted to the AUVA Trauma Center Salzburg between February 2015 and December 2021. DOAC plasma levels were analysed prior to surgery. Patients were categorized into four DOAC groups: Group A < 30 ng/mL, Group B 30-49 ng/mL, Group C 50-79 ng/mL, and Group D ≥ 80 ng/mL. Haemoglobin concentration was measured upon admission, prior to surgery, after ICU/IMC admission, and on day 1 and 2 post-surgery. Difference in the blood loss via drains, transfusion requirements and time to surgery were compared.
RESULTS
RESULTS
A total of 155 subjects fulfilled the predefined inclusion criteria. The median age of the predominantly female patients was 86 (80-90) years. Haemoglobin concentration in Group D was lower upon admissions but did not reach statistical significance. The decrease in haemoglobin concentration over the entire observation time was comparable between groups. Blood transfusion requirements were significantly higher in Group D compared to Group A and B (p = 0.0043). Time to surgery, intra- and postoperative blood loss via drains were not different among groups.
CONCLUSION
CONCLUSIONS
No strong association between the DOAC plasma levels and perioperative blood loss was detected. Higher transfusion rates in patients with DOAC levels ≥ 80 ng/mL were primarily related to lower admission haemoglobin levels. DOAC concentration measurement is feasible and expedites time to surgery.
Identifiants
pubmed: 35841427
doi: 10.1007/s00068-022-02041-7
pii: 10.1007/s00068-022-02041-7
doi:
Substances chimiques
Hemoglobins
0
Anticoagulants
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
165-172Informations de copyright
© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.
Références
Karampampa K, Ahlbom A, Michaëlsson K, Andersson T, Drefahl S, Modig K. Declining incidence trends for hip fractures have not been accompanied by improvements in lifetime risk or post-fracture survival–A nationwide study of the Swedish population 60 years and older. Bone. 2015;78:55–61.
doi: 10.1016/j.bone.2015.04.032
pubmed: 25933944
Veronese N, Maggi S. Epidemiology and social costs of hip fracture. Injury. 2018;49(8):1458–60.
doi: 10.1016/j.injury.2018.04.015
pubmed: 29699731
Griffiths R, Babu S, Dixon P, Freeman N, Hurford D, Kelleher E, Moppett I, Ray D, Sahota O, Shields M, et al. Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists. Anaesthesia. 2021;76(2):225–37.
doi: 10.1111/anae.15291
pubmed: 33289066
Pincus D, Ravi B, Wasserstein D, Huang A, Paterson JM, Nathens AB, Kreder HJ, Jenkinson RJ, Wodchis WP. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA. 2017;318(20):1994–2003.
doi: 10.1001/jama.2017.17606
pubmed: 29183076
pmcid: 5820694
Daugaard C, Pedersen AB, Kristensen NR, Johnsen SP. Preoperative antithrombotic therapy and risk of blood transfusion and mortality following hip fracture surgery: a Danish nationwide cohort study. Osteoporos Int. 2019;30(3):583–91.
doi: 10.1007/s00198-018-4786-0
pubmed: 30498889
Douketis JD, Spyropoulos AC, Duncan J, Carrier M, Le Gal G, Tafur AJ, Vanassche T, Verhamme P, Shivakumar S, Gross PL, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med. 2019;179(11):1469–78.
doi: 10.1001/jamainternmed.2019.2431
pubmed: 31380891
pmcid: 6686768
Shah R, Sheikh N, Mangwani J, Morgan N, Khairandish H. Direct oral anticoagulants (DOACs) and neck of femur fractures: Standardising the perioperative management and time to surgery. J Clin Orthop Trauma. 2021;12(1):138–47.
doi: 10.1016/j.jcot.2020.08.005
pubmed: 33716439
Douxfils J, Adcock DM, Bates SM, Favaloro EJ, Gouin-Thibault I, Guillermo C, Kawai Y, Lindhoff-Last E, Kitchen S, Gosselin RC. 2021 Update of the international council for standardization in haematology recommendations for laboratory measurement of direct oral anticoagulants. Thromb Haemost. 2021;121(8):1008–20.
doi: 10.1055/a-1450-8178
pubmed: 33742436
Lohrmann GM, Atwal D, Augoustides JG, Askar W, Patel PA, Ghadimi K, Makar G, Gutsche JT, Shamoun FE, Ramakrishna H. Reversal agents for the new generation of oral anticoagulants: implications for the perioperative physician. J Cardiothorac Vasc Anesth. 2016;30(3):823–30.
doi: 10.1053/j.jvca.2016.01.005
pubmed: 27080265
Sennesael AL, Larock AS, Douxfils J, Elens L, Stillemans G, Wiesen M, Taubert M, Dogné JM, Spinewine A, Mullier F. Rivaroxaban plasma levels in patients admitted for bleeding events: insights from a prospective study. Thromb J. 2018;16:28.
doi: 10.1186/s12959-018-0183-3
pubmed: 30455596
pmcid: 6231259
Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019;23(1):98.
doi: 10.1186/s13054-019-2347-3
pubmed: 30917843
pmcid: 6436241
Seiffge DJ, Kägi G, Michel P, Fischer U, Béjot Y, Wegener S, Zedde M, Turc G, Cordonnier C, Sandor PS, et al. Rivaroxaban plasma levels in acute ischemic stroke and intracerebral hemorrhage. Ann Neurol. 2018;83(3):451–9.
doi: 10.1002/ana.25165
pubmed: 29394504
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.
doi: 10.1016/0021-9681(87)90171-8
pubmed: 3558716
Carson JL, Stanworth SJ, Dennis JA, Trivella M, Roubinian N, Fergusson DA, Triulzi D, Dorée C, Hébert PC. Transfusion thresholds for guiding red blood cell transfusion. Cochrane Database Syst Rev. 2021;12(12):Cd002042.
Tran T, Delluc A, de Wit C, Petrcich W, Le Gal G, Carrier M. The impact of oral anticoagulation on time to surgery in patients hospitalized with hip fracture. Thromb Res. 2015;136(5):962–5.
doi: 10.1016/j.thromres.2015.09.017
pubmed: 26428416
Bruckbauer M, Prexl O, Voelckel W, Ziegler B, Grottke O, Maegele M, Schöchl H. Impact of direct oral anticoagulants in patients with hip fractures. J Orthop Trauma. 2019;33(1):e8–13.
doi: 10.1097/BOT.0000000000001329
pubmed: 30277979
Shani M, Yahalom R, Comaneshter D, Holtzman K, Blickstein D, Cohen A, Lustman A. Should patients treated with oral anti-coagulants be operated on within 48 h of hip fracture? J Thromb Thrombolysis. 2021;51(4):1132–7.
doi: 10.1007/s11239-020-02261-x
pubmed: 32889619
Gong LN, Li JY, Li XF, Chu J. Effect of preinjury use of direct oral anticoagulants vs. Vitamin K antagonists on outcomes of hip fracture: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci. 2021;25(20):6260–70.
Mullins B, Akehurst H, Slattery D, Chesser T. Should surgery be delayed in patients taking direct oral anticoagulants who suffer a hip fracture? A retrospective, case-controlled observational study at a UK major trauma centre. BMJ Open. 2018;8(4): e020625.
doi: 10.1136/bmjopen-2017-020625
pubmed: 29705761
pmcid: 5931299
Tarrant SM, Catanach MJ, Sarrami M, Clapham M, Attia J, Balogh ZJ. Direct oral anticoagulants and timing of hip fracture surgery. J Clin Med. 2020;9(7):2200.
doi: 10.3390/jcm9072200
pubmed: 32664649
pmcid: 7408859
Brown A, Zmich Z, Roberts A, Lipof J, Judd KT. Expedited surgery in geriatric hip fracture patients taking direct oral anticoagulants is not associated with increased short-term complications or mortality rates. OTA Int. 2020;3(3): e089.
doi: 10.1097/OI9.0000000000000089
pubmed: 33937710
pmcid: 8022910
Kaserer A, Kiavialaitis GE, Braun J, Schedler A, Stein P, Rössler J, Spahn DR, Studt JD. Impact of rivaroxaban plasma concentration on perioperative red blood cell loss. Transfusion. 2020;60(1):197–205.
doi: 10.1111/trf.15560
pubmed: 31682296
Oberladstätter D, Voelckel W, Schlimp C, Zipperle J, Ziegler B, Grottke O, Schöchl H. A prospective observational study of the rapid detection of clinically-relevant plasma direct oral anticoagulant levels following acute traumatic injury. Anaesthesia. 2021;76(3):373–80.
doi: 10.1111/anae.15254
pubmed: 32946123
Viktil KK, Lehre I, Ranhoff AH, Molden E. Serum concentrations and elimination rates of direct-acting oral anticoagulants (DOACs) in older hip fracture patients hospitalized for surgery: a pilot study. Drugs Aging. 2019;36(1):65–71.
doi: 10.1007/s40266-018-0609-4
pubmed: 30411284
Leer-Salvesen S, Dybvik E, Ranhoff AH, Husebø BL, Dahl OE, Engesæter LB, Gjertsen JE. Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients? Eur Geriatr Med. 2020;11(4):563–9.
doi: 10.1007/s41999-020-00319-w
pubmed: 32361891
pmcid: 7438280
Schermann H, Gurel R, Gold A, Maman E, Dolkart O, Steinberg EL, Chechik O. Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications. Injury. 2019;50(2):398–402.
doi: 10.1016/j.injury.2018.10.033
pubmed: 30391072
Schuetze K, Eickhoff A, Dehner C, Gebhard F, Richter PH. Impact of oral anticoagulation on proximal femur fractures treated within 24 h—a retrospective chart review. Injury. 2019;50(11):2040–4.
doi: 10.1016/j.injury.2019.09.011
pubmed: 31543315