Direkte orale Antikoagulanzien – eine medizinische Innovation oder eine Herausforderung in der Alterstraumatologie? Einblicke in die Praxis & Erkenntnisse rund um das perioperative Management
Loading...
Files
Date
Authors
Publisher
Philipps-Universität Marburg
Supervisors
Abstract
Currently, one in ten geriatric trauma patients is permanently anticoagulated. Vitamin K antagonists
(VKA) and direct oral anticoagulants (DOAC) are available for oral anticoagulation. DOACs,
meanwhile, account for more than 60 % of the prescriptions. These are a relatively new class of agents
the anticoagulant effect of which is based on the inhibition of specific coagulation factors (factor (F)-
IIa, FXa). Due to lower bleeding risks, shorter half-life periods, no need for regular monitoring and less
frequent drug and food interactions, it is foreseeable that DOACs will continue to gain importance and
gradually replace the established VKA. In about 15 % of the cases, patients need to interrupt their
anticoagulant medication for surgery. Despite increasing experience and existing recommendations,
perioperative DOAC management is a challenge in clinical practice.
The present study investigated the use of DOAC in the perioperative setting of geriatric traumatology
at the Center for Orthopaedics and Trauma Surgery (CfOU) of the University Hospital Giessen and
Marburg – Marburg site. In addition to a presentation of the previous perioperative approach, this work
was intended to evaluate whether the DOAC use delays the timing of surgery in patients with proximal
femur fracture. Further, the adherence to existing recommendations was to be analyzed and a
preoperative checklist developed, based on the obtained results.
In the retrospective study, the medical records of all >60-year-old patients with a DOAC medication
who were hospitalized at the CfOU from 2015–2016 due to a surgical procedure were evaluated. Patient
characteristics, surgery-specific parameters (e.g., bleeding risk of the surgery) and aspects of the
perioperative course (e.g., occurrence of complications) were examined. In addition to own data, the
current state of knowledge determined via a literature search was also taken into account in the
development of the checklist for clinical practice. 112 patients (FIIa- Inhibitor: n=19, 17 %; FXa-
Inhibitor: n=93, 83 %) with a mean age of 78±8 years were included. The collective consisted of (multi-
) morbid patients under polypharmacy (number of drugs at discharge 10±3) with a high prevalence for
a renal function impairment (anamnestic n=20, 17,9 %, laboratory n=66, 74,1 %). The most common
indication for a DOAC use was atrial fibrillation (n=68, 73,9 %). 70 % of the primary surgeries were
associated with a low bleeding risk. The most common diagnosis was lower extremity fractures (n=28,
30.1 %). The mean duration between the inpatient admission and the surgical care was 34±38 h, and the
mean duration of the surgery was 79±53 minutes. The anticoagulant medication was paused
perioperatively in 98 % of the patients (preoperative 48±44 h, postoperative 238±240 h). There was no
significant difference in the preoperative pause duration subject to the intraoperative bleeding risk
(p=0,466). 90 % of the patients received enoxaparin (ClexaneÒ); 60 % of them in a therapeutic dosage,
and, thus, underwent bridging. Significant differences in the perioperative approach between the FIIaand
FXa- Inhibitor groups were absent. At least one complication occurred postoperatively in 43 % of
the patients. Systemic or mechanical complications predominated. Five patients (3,8 %) experienced a
bleeding complication, 16 patients (12,1 %) experienced a hemoglobin drop and one patient (0,8 %)
experienced a thromboembolic event.
A comparison of the perioperative management with existing recommendations revealed a lack of
adherence, particularly to the postoperative procedure in terms of prolonging pausing. Patients with
high-risk constellations (e.g., severely impaired renal function, high intraoperative bleeding risk), who
were managed according to the recommendations, were excluded. The data analysis revealed a variety
of factors that should be considered in perioperative management and explored preoperatively. Based
on the study results and the literature review, a checklist was developed for the CfOU.
A proximal femoral fracture is a common injury in geriatric traumatology, where the timing of the
surgery strongly influences the morbidity and the mortality. Therefore, clear guidelines exist for surgical
management. The DOAC use is considered a risk factor for delayed surgical care. In the present
collective, patients with a proximal femur fracture (16 % of the total collective) underwent surgery
significantly (p=0,043) earlier than patients with other injuries. The mean time between the admission
and the surgery (17±9 h) was shorter at CfOU than in comparable studies.
In sum, the results indicate a heterogeneous approach in the perioperative setting despite clear
recommendations. To improve this situation, further prospective studies are needed, especially for nonelective
procedures as well as for high-risk constellations. The lack of comparison with nonanticoagulated
patients and patients under VKA as well as the lack of differentiation between elective
and emergency surgery limits the validity of the study. The developed checklist can help to optimize the
perioperative procedure and to increase the patient safety. The checklist could also be useful for the
design and data collection of future studies. Ultimately, however, the procedure for each patient remains
a case-by-case decision due to his or her individual characteristics and risk factors.
Review
Metadata
Contributors
Supervisor:
Dates
Created: 2022Issued: 2023-06-05Updated: 2023-06-05
Faculty
Medizin
Publisher
Philipps-Universität Marburg
Language
ger
Data types
DoctoralThesis
DFG-subjects
AntikoagulationDOAK perioperativDOAKNOAK perioperativNOAK
DDC-Numbers
610
show more
Hepper, Alexandra Kim Isabell: Direkte orale Antikoagulanzien – eine medizinische Innovation oder eine Herausforderung in der Alterstraumatologie? Einblicke in die Praxis & Erkenntnisse rund um das perioperative Management. : Philipps-Universität Marburg 2023-06-05. DOI: https://doi.org/10.17192/z2022.0374.
License
This item has been published with the following license: In Copyright