PB0481 - Are levels of direct anticoagulant at the onset of hip fracture surgery associated with post-surgery bleeding?

Background: Hip fractures are a major cause of morbidity and mortality in elderly population, with 1-year mortality rates up to 20%. Early surgery within 48 hours is associated with better morbidity and mortality post-surgery. In patients treated with direct oral anticoagulants (DOACs), awaiting for the anticoagulant effect to subside in order to avoid excess surgical bleeding, may lead to delayed hip fracture surgery (HFS). There is limited data regarding the effect of DOAC levels at surgery on post-surgical bleeding

Aims: To study the association between levels of DOACs at the start of HFS and post-surgical bleeding in elderly patients

Methods: A retrospective cohort study of patients admitted to orthopedic or geriatric wards at Sheba Medical Center, with hip fractures between January 2016 to October 2019. Out of 1749 patients (age>65) with HFS 137 patients treated with DOACs and assessed for DOAC blood levels were studied. Half-life and predicted level at surgery start were computed from sequential pre-surgery blood levels. Outcome was post-surgery bleeding divided into three bleeding classifications: Major bleed (MB), clinically relevant non major bleed (CRNMB) and No bleed

Results: Of the 137 patients, 64 (47%) had MB, 47 (34%) had CRNMB, 26 (19%) did not bleed. The predicted median level at surgery was 14.59 ng/ml for MB patients, 11.20 ng/ml for CRNMB patients and 14.41 ng/ml for patients with no bleeding with no significant difference among the three groups was found (p=0.86). In all groups most patients (69%-70%) had a level ≤ 30 ng/ml at surgery start (p= 0.98). (Figure)

Conclusion(s): Levels of DOAC at surgery start were not associated with post-surgical bleeding in elderly DOAC treated patients who underwent HFS. Higher DOAC level pre-surgery should not be the cause to delay surgery and consequently more patients could be operated upon in the desired 48 hours time frame