Anticoagulation Management in Geriatric Orthopedic Trauma Patients
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GERIATRIC ORTHOPEDICS (C QUATMAN AND C QUATMAN-YATES, SECTION EDITORS)
Anticoagulation Management in Geriatric Orthopedic Trauma Patients Jensa C. Morris 1 & Mary I. O’Connor 2 Accepted: 28 October 2020 / Published online: 18 November 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review This article will review the perioperative management of geriatric patients on anticoagulants who present for non-elective orthopedic surgery. Recent Findings Our understanding of best practices in perioperative anticoagulation management has advanced significantly over the last 5 years. More patients are presenting for surgery on direct oral anticoagulants which require a different approach than the vitamin K antagonist, warfarin. We have come to better appreciate the importance of time to the operating room on outcomes, specifically in hip fracture surgery. Regional anesthesia now has standardized guidelines for preprocedure anticoagulation interruption. Prothrombin complex concentrate has increasing acceptance for warfarin reversal preoperatively. Reversal agents are now available for the direct oral anticoagulants but are not recommended for standard use preprocedure. And there has been a shift away from routine use of bridging anticoagulation periprocedure. Summary A team-based approach with input from the surgical, anesthesia, and internal medicine or geriatric team preoperatively is critical to the management of perioperative anticoagulation. Keywords Geriatric . Anticoagulation . Hip fracture surgery . Trauma . Perioperative care . Atrial fibrillation
Introduction The challenge addressed by this article is the management of a patient on therapeutic anticoagulation who requires urgent or emergent orthopedic surgery. We will discuss perioperative management of commonly used anticoagulants in the outpatient setting including the vitamin K antagonist, warfarin, and the direct oral anticoagulants (DOAC), rivaroxaban, apixaban, edoxaban, and dabigatran. As injectable agents are not commonly prescribed for long-term therapy in outpatients, low molecular weight heparin and fondaparinux will not be addressed. Prevention of venous thromboembolism postoperatively is a review unto itself and will not be discussed here. This article is part of the Topical Collection on Geriatric Orthopedics * Jensa C. Morris [email protected] 1
Hospitalist Service, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA
2
Department of Orthopaedics & Rehabilitation, Yale University, New Haven, USA
Furthermore, the perioperative management of antiplatelet agents such as aspirin, clopidogrel, and ticagrelor is out of the scope of this review. The term anticoagulation will refer to full, therapeutic anticoagulation used to treat venous thromboembolism or prevent stroke in patients with mechanical valves or atrial fibrillation. Lower doses of anticoagulation used to prevent blood clots will be differentiated with the term DVT prophylaxis. Anticoagulation includes warfarin dosed to a target IN
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