Yassa Rafik, Khalfaoui Mahdi Yacine, Hujazi Ihab, Sevenoaks Hannah, Dunkow Paul
North West Deanery, Manchester, UK.
Blackpool Victoria Teaching Hospitals, Blackpool, UK.
EFORT Open Rev. 2017 Sep 21;2(9):394-402. doi: 10.1302/2058-5241.2.160083. eCollection 2017 Sep.
Hip fractures are common and increasing with an ageing population. In the United Kingdom, the national guidelines recommend operative intervention within 36 hours of diagnosis. However, long-term anticoagulant treatment is frequently encountered in these patients which can delay surgical intervention. Despite this, there are no set national standards for management of drug-induced coagulopathy pre-operatively in the context of hip fractures.The aim of this study was to evaluate the management protocols available in the current literature for the commonly encountered coagulopathy-inducing agents.We reviewed the current literature, identified the reversal agents used in coagulopathy management and assessed the evidence to determine the optimal timing, doses and routes of administration.Warfarin and other vitamin K antagonists (VKA) can be reversed effectively using vitamin K with a dose in the range of 2 mg to 10 mg intravenously to correct coagulopathy.The role of fresh frozen plasma is not clear from the current evidence while prothrombin complex remains a reliable and safe method for immediate reversal of VKA-induced coagulopathy in hip fracture surgery or failed vitamin K treatment reversal.The literature suggests that surgery should not be delayed in patients on classical antiplatelet medications (aspirin or clopidogrel), but spinal or regional anaesthetic methods should be avoided for the latter. However, evidence regarding the use of more novel antiplatelet medications (e.g. ticagrelor) and direct oral anticoagulants remains a largely unexplored area in the context of hip fracture surgery. We suggest treatment protocols based on best available evidence and guidance from allied specialties.Hip fracture surgery presents a common management dilemma where semi-urgent surgery is required. In this article, we advocate an evidence-based algorithm as a guide for managing these anticoagulated patients. Cite this article: 2017;2:394-402. DOI: 10.1302/2058-5241.2.160083.
髋部骨折很常见，且随着人口老龄化呈上升趋势。在英国，国家指南建议在诊断后36小时内进行手术干预。然而，这些患者中经常会遇到长期抗凝治疗，这可能会延迟手术干预。尽管如此，对于髋部骨折患者术前药物性凝血病的管理，目前尚无既定的国家标准。本研究的目的是评估当前文献中针对常见的致凝血病药物的管理方案。我们回顾了当前文献，确定了用于凝血病管理的逆转剂，并评估了证据以确定最佳的时机、剂量和给药途径。华法林和其他维生素K拮抗剂（VKA）可通过静脉注射2毫克至10毫克范围内的维生素K有效逆转，以纠正凝血病。从目前的证据来看，新鲜冰冻血浆的作用尚不明确，而凝血酶原复合物仍然是髋部骨折手术中或维生素K治疗逆转失败时立即逆转VKA所致凝血病的可靠且安全的方法。文献表明，服用经典抗血小板药物（阿司匹林或氯吡格雷）的患者不应延迟手术，但对于后者应避免使用脊髓或区域麻醉方法。然而，在髋部骨折手术的背景下，关于使用更新型抗血小板药物（如替格瑞洛）和直接口服抗凝剂的证据在很大程度上仍未得到探索。我们根据现有最佳证据和相关专业的指导建议了治疗方案。髋部骨折手术带来了一个常见的管理难题，即需要进行半紧急手术。在本文中，我们提倡采用循证算法作为管理这些抗凝患者的指南。引用本文：2017；2：394 - 402。DOI：10.1302/2058 - 5241.2.160083。
