Aziz Sheweidin, Almeida Krishan, Taylor Grahame
Trauma and Orthopaedics, Leicester General Hospital, Leicester, Leicester, UK
Trauma and Orthopaedics department, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, Nottingham, UK.
BMJ Evid Based Med. 2021 Feb;26(1):22-23. doi: 10.1136/bmjebm-2019-111317. Epub 2020 Apr 24.
Currently, there are no national protocols in place for managing hip fracture patients on direct oral anticoagulants (DOACs). Hence, various local management protocols exist. We compared three different local protocols and a control group to assess blood loss and time delay to theatre.
Sequential data were collected for 120 hip fracture patients in four groups; wait 24 hours from last dose, wait 48 hours, perform DOAC levels and control.
DOAC use in our hip fracture patients was 14%. Median haemoglobin (Hb) drop between the three protocol groups showed no significant difference (13.5, 21.5 and 16.0 g/L) (Kruskal-Wallis, p=0.9). Median Hb drop in the control group was 16.0 g/L versus 17.5 g/L in the protocol groups combined (Mann Whitney-U, p=0.7). Average Hb drop in the control group was 19.2 g/L and in the protocol groups was 22.1 g/L; a 15% greater blood loss with DOACs. The frequency distribution of blood loss was different between the control and protocol groups, but not between the protocol groups. The highest Hb drop in the control group was 3.4 g/L, while in the protocol groups, it was 7.8 g/L. Median Hb on arrival to hospital was higher in the control group (124 g/L) compared with the three protocol groups (87 g/L) (t-test p<0.0001). Transfusion rates of up to 40% were observed within the DOAC groups compared with zero in the control group.Median time to theatre between the three protocol groups was significantly different at 17.5, 53.3 and 22.5 hours, respectively (Kruskal-Wallis, p<0.0001).
DOACs caused increased bleeding and delays to theatre in hip fracture patients, however the largest Hb difference was already apparent on arrival. Subsequent blood loss was minimal on average; a few patients bled heavily. Prolonged waiting made no significant difference to blood loss, but caused delay to theatre leading to financial losses from best practice tariff.
目前，尚无针对使用直接口服抗凝剂（DOACs）的髋部骨折患者的全国性管理方案。因此，存在各种地方管理方案。我们比较了三种不同的地方方案和一个对照组，以评估失血量和手术延迟时间。
收集了四组120例髋部骨折患者的序贯数据；从上一剂起等待24小时、等待48小时、检测DOAC水平以及对照组。
我们的髋部骨折患者中DOAC的使用率为14%。三个方案组之间血红蛋白（Hb）下降中位数无显著差异（分别为13.5、21.5和16.0g/L）（Kruskal-Wallis检验，p=0.9）。对照组Hb下降中位数为16.0g/L，而联合方案组为17.5g/L（Mann Whitney-U检验，p=0.7）。对照组平均Hb下降为19.2g/L，方案组为22.1g/L；使用DOACs时失血量增加15%。对照组和方案组之间失血量的频率分布不同，但方案组之间无差异。对照组最高Hb下降为3.4g/L，而方案组为7.8g/L。入院时对照组的Hb中位数（124g/L）高于三个方案组（87g/L）（t检验，p<0.0001）。DOAC组的输血率高达40%，而对照组为零。三个方案组之间的手术中位时间有显著差异，分别为17.5、53.3和22.5小时（Kruskal-Wallis检验，p<0.0001）。
DOACs导致髋部骨折患者出血增加和手术延迟，然而最大的Hb差异在入院时就已很明显。随后平均失血量最小；少数患者出血严重。延长等待时间对失血量无显著影响，但导致手术延迟，造成最佳实践收费方面的经济损失。
