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Meinig R, Jarvis S, Salottolo K, Nwafo N, McNair P, Harrison P, Morgan S, Duane T, Woods B, Nentwig M, Kelly M, Cornutt D, Bar-Or D. Propensity matched analysis examining the effect of passive reversal of direct oral anticoagulants on blood loss and the need for transfusions among traumatic geriatric hip fractures. Eur J Med Res 2023; 28:241. [PMID: 37475008 PMCID: PMC10360353 DOI: 10.1186/s40001-023-01053-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/08/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Reversal of direct oral anticoagulants (DOACs) is currently recommended prior to emergent surgery, such as surgical intervention for traumatic geriatric hip fractures. However, reversal methods are expensive and timely, often delaying surgical intervention, which is a predictor of outcomes. The study objective was to examine the effect of DOAC reversal on blood loss and transfusions among geriatric patients with hip fractures. METHODS This retrospective propensity-matched study across six level I trauma centers included geriatric patients on DOACs with isolated fragility hip fractures requiring surgical intervention (2014-2017). Outcomes included: intraoperative blood loss, intraoperative pRBCs, and hospital length of stay (HLOS). RESULTS After matching there were 62 patients (31 reversed, 31 not reversed), 29 patients were not matched. The only reversal method utilized was passive reversal (waiting ≥ 24 hours for elimination). Passively reversed patients had a longer time to surgery (mean, 43 vs. 18 hours, p < 0.01). Most patients (92%) had blood loss (90% passively reversed, 94% not reversed); the median volume of blood loss was 100 mL for both those groups, p = 0.97. Thirteen percent had pRBCs transfused (13% passively reversed and 13% not reversed); the median volume of pRBCs transfused was 525 mL for those passively reversed and 314 mL for those not reversed, p = 0.52. The mean HLOS was significantly longer for those passively reversed (7 vs. 5 days, p = 0.001). CONCLUSIONS Passive DOAC reversal for geriatric patients with isolated hip fracture requiring surgery may be contributing to delayed surgery and an increased HLOS without having a significant effect on blood loss or transfusions. These data suggest that passive DOAC reversal may not be necessary prior to surgical repair of isolated hip fracture.
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Affiliation(s)
- Richard Meinig
- Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO, 80907, USA
| | - Stephanie Jarvis
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Kristin Salottolo
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Nnamdi Nwafo
- Swedish Medical Center, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Patrick McNair
- St. Anthony Hospital, 11600 W 2nd Plaza, Lakewood, CO, 80228, USA
| | - Paul Harrison
- Wesley Medical Center, 550 North Hillside St. Wichita, Wichita, KS, 67214, USA
| | - Steven Morgan
- Swedish Medical Center, 501 East Hampden Ave, Englewood, CO, 80113, USA
| | - Therese Duane
- Medical City Plano, 3901 West 15th Street, Plano, TX, 75075, USA
| | - Bradley Woods
- Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO, 64132, USA
| | - Michelle Nentwig
- Wesley Medical Center, 550 North Hillside St. Wichita, Wichita, KS, 67214, USA
| | - Michael Kelly
- Penrose Hospital, 2222 N Nevada Ave, Colorado Springs, CO, 80907, USA
| | - David Cornutt
- Regional West Medical Center, 4021 Ave B, Scottsbluff, NE, 69361, USA
| | - David Bar-Or
- Injury Outcomes Network (ION) Research, 501 East Hampden Ave, Englewood, CO, 80113, USA.
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Meinig R, Cornutt D, Jarvis S, Salottolo K, Kelly M, Harrison P, Nentwig M, Morgan S, Nwafo N, McNair P, Banerjee R, Woods B, Bar-Or D. Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions. J Clin Orthop Trauma 2020; 14:45-51. [PMID: 33717896 PMCID: PMC7920139 DOI: 10.1016/j.jcot.2020.09.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Warfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear. METHODS This was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the "wait and watch" method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery. RESULTS There were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery. CONCLUSIONS Partial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.
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Key Words
- AAOS, American Academy of Orthopedic Surgeons
- ANOVA, analysis of variance
- CVA, cerebrovascular accident
- DOAC, direct oral anticoagulants
- DVT, deep vein thrombosis
- FFP, fresh frozen plasma
- Geriatric
- HIPAA, health insurance accountability and assurance act
- HLOS, hospital length of stay
- Hip fracture
- ICD, international classification of diseases
- ICU LOS, intensive care unit length of stay
- INR, international normalized ratio
- ION, Injury Outcomes Network
- IQR, interquartile range
- IV, intravenous
- MI, myocardial infarction
- PCC, prothrombin complex concentrates
- PE, pulmonary embolism
- Reversal
- SD, standard deviation
- TQIP, Trauma Quality Improvement Program
- Trauma
- Warfarin
- aPCC, activated prothrombin complex concentrates
- mL, milliliters
- pRBC, packed red blood cells
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Affiliation(s)
- Richard Meinig
- Orthopedic Surgery and Trauma, Penrose Hospital, 1263 Lake Plaza Dr, Colorado Springs, CO, 80906, USA
| | - David Cornutt
- Emergency Medicine, Regional West Medical Center, 4021 Avenue B, Scottsbluff, NE, 69361, USA
| | - Stephanie Jarvis
- Injury Outcomes Network (ION) Research, 501 E. Hampden Ave, Englewood, CO, 80113, USA
| | - Kristin Salottolo
- Injury Outcomes Network (ION) Research, 501 E. Hampden Ave, Englewood, CO, 80113, USA
| | - Michael Kelly
- Orthopedic Surgery and Trauma, Penrose Hospital, 1263 Lake Plaza Dr, Colorado Springs, CO, 80906, USA
| | - Paul Harrison
- General, Trauma, & Orthopedic Surgery, Wesley Medical Center, 3242 E. Murdock Street, Wichita, KS, 67208, USA
| | - Michelle Nentwig
- General, Trauma, & Orthopedic Surgery, Wesley Medical Center, 3242 E. Murdock Street, Wichita, KS, 67208, USA
| | - Steven Morgan
- Orthopedic Surgery, Internal Medicine, Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - Nnamdi Nwafo
- Orthopedic Surgery, Internal Medicine, Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - Patrick McNair
- Orthopedic Sports Medicine and Trauma, St. Anthony Hospital, 11600 West 2nd Plaza, Lakewood, CO, 80228, USA
| | - Rahul Banerjee
- Orthopaedic Trauma, Medical City Plano, 1600 Coit Rd Suite 104, Plano, TX, 75075, USA
| | - Bradley Woods
- General Surgery, Research Medical Center, 2316 East Meyer Boulevard, Kansas City, MO, 64132, USA
| | - David Bar-Or
- Injury Outcomes Network (ION) Research, 501 E. Hampden Ave, Englewood, CO, 80113, USA
- Corresponding author. Injury Outcomes Network (ION) Research, 501 E Hampden Ave, Englewood, CO, 80113, USA.
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Sieg A, Nappi J. Evaluation of Dosing Practices of Rivaroxaban and Dabigatran. J Pharm Technol 2015; 31:149-154. [DOI: 10.1177/8755122514567923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Anticoagulation is standard practice for the prevention and treatment of thromboembolic events. Two of the newer agents, rivaroxaban (Xarelto) and dabigatran (Pradaxa) are being utilized frequently in the inpatient and outpatient settings. Prescribers may not appreciate the need for dose reduction in the setting of renal insufficiency. Objective: The objective of this study was to evaluate whether rivaroxaban and dabigatran were dosed according to recommendations in the package insert for patients with renal insufficiency. Methods: Eligible patients were those >18 years of age who received rivaroxaban or dabigatran as an inpatient or had a prescription filled from the outpatient pharmacy. The use of the Cockcroft–Gault equation was utilized to calculate creatinine clearance to evaluate whether patients had appropriate manufacturer recommended dose reductions based on their renal function. Results: There were very few patients (8 of 355, or 2.3%) who should have received a reduced dose when creatinine clearance was calculated utilizing actual body weight. In those patients with renal insufficiency, 3 of 6 (50.0%) patients receiving rivaroxaban and 1 of 2 (50%) patients receiving dabigatran were appropriately dosed. When ideal body weight was substituted for creatinine clearance calculation, there were 15 patients receiving rivaroxaban and 10 patients receiving dabigatran who fell below the creatinine clearance threshold for dose reduction. Conclusions: Based on this evaluation, very few patients required a dose reduction due to renal insufficiency. It is important for clinicians to always monitor renal function when utilizing these medications to optimize the benefits of the new oral anticoagulants while limiting potential deleterious effects. Furthermore, it is necessary to ensure that actual body weight is being utilized for creatinine clearance calculations with the new oral anticoagulants and not to base dosing on estimated glomerular filtration rate or other calculated creatinine clearance as this could lead to inappropriate dose reductions.
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Affiliation(s)
- Adam Sieg
- Memorial Hermann—Texas Medical Center, Houston, TX, USA
| | - Jean Nappi
- South Carolina College of Pharmacy, Medical University of South Carolina Campus, Charleston, SC, USA
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Abstract
Geriatric patients are at higher risk for hemorrhagic complications after surgery and traumatic injuries. The geriatric population is more likely to take anticoagulant or antiplatelet medications. Chronic disease, autoimmune disease, and nutritional deficiencies can lead to coagulation factor and platelet disorders. One must be familiar with the current anticoagulant and antiplatelet medications, their mechanism of action, and reversal agents to properly care for this group of patients. The new oral anticoagulants do not have Food and Drug Administration (FDA) approved reversal agents, but known procoagulant agents with other FDA indications may be effective.
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Affiliation(s)
- Philbert Y Van
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L-611, Portland, OR 97239-3098, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L-611, Portland, OR 97239-3098, USA.
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