Academic Clinical Fellow, Anaesthesia and Critical Care, Division of Clinical Neuroscience, University of Nottingham, UK.
Trauma and Orthopaedic Surgical Registrar, Centre for Trauma Sciences, Blizzard Institute, Queen Mary University of London, UK.
Injury. 2021 Nov;52(11):3206-3216. doi: 10.1016/j.injury.2021.09.005. Epub 2021 Sep 12.
Increasing numbers of patients are taking Direct Oral Anticoagulants at the time of hip fracture. Evidence is limited on how and if the effects of DOAC's should be reversed before surgical fixation. Wide variations in practice exist. We conducted a systematic review to investigate outcomes for three reversal strategies. These were: "watch and wait" (also referred to as "time-reversal"), plasma product reversal and reversal with specific antidotes.
A systematic search was conducted using multiple databases. Results were obtained for studies directly comparing different DOAC reversal strategies in hip fracture patients and for studies comparing DOAC-taking hip fracture patients (including patients "reversed" using any method and "non-reversed" patients) against matched controls taking either a vitamin-K antagonist or not receiving anticoagulation therapy. This allowed construction of a network meta-analysis to indirectly compare outcomes between "reversed" and "non-reversed" DOAC patients. With respect to "watch and wait"/"time-reversal", a cut-off time to surgery of 36 hours was used to distinguish between "time-reversed" and "non time-reversed" DOAC patients. The primary outcome was early/inpatient mortality, reported as Odds Ratios (OR).
No studies investigating plasma products or reversal agents specifically in hip fracture patients were obtained. Fourteen studies were suitable for analysis of "watch and wait"/"time- reversal". Two studies directly compared "time-reversed" and "non time-reversed" DOAC-taking hip fracture patients (58 "time-reversed", 62 "non time-reversed"). From 12 other studies we used indirect comparisons between "time-reversed" and "non time-reversed" DOAC patients (total, 357 "time-reversed", 282 "non time-reversed"). We found no statistically significant differences in mortality outcomes between "time-reversal" and "non time-reversal" (OR 1.48 [95%CI: 0.29-7.53]). We also did not find a statistically significant difference between "time reversal" and "non time-reversal" in terms of blood transfusion requirements (OR 1.16 [95% CI 0.42-3.23]). However, several authors described that surgical delay is associated with worse outcomes related to prolonged hospitalisation, and that operating within 36 hours is safe.
We suggested against "watch and wait" to reverse the DOAC effect in hip fractures. Further work is required to assess the optimal timing for surgery as well as the use of plasma products or specific antidotes in DOAC-taking hip fracture patients.
越来越多的髋部骨折患者在服用直接口服抗凝剂。关于在进行手术固定之前，应该如何以及是否应该逆转 DOAC 的作用，证据有限。实践中存在广泛的差异。我们进行了一项系统评价，以调查三种逆转策略的结果。这些策略是：“观察等待”（也称为“时间逆转”）、血浆制品逆转和使用特定解毒剂逆转。
使用多个数据库进行了系统搜索。结果获得了直接比较髋部骨折患者中不同 DOAC 逆转策略的研究结果，以及比较接受 DOAC 治疗的髋部骨折患者（包括使用任何方法进行“逆转”和未接受抗凝治疗的“非逆转”患者）与接受维生素 K 拮抗剂或未接受抗凝治疗的匹配对照患者的研究结果。这允许构建一个网络荟萃分析，以间接比较“逆转”和“非逆转”DOAC 患者之间的结果。关于“观察等待”/“时间逆转”，使用手术前 36 小时的截止时间来区分“时间逆转”和“非时间逆转”DOAC 患者。主要结局是早期/住院死亡率，报告为优势比（OR）。
没有获得专门针对髋部骨折患者的血浆制品或逆转剂的研究。有 14 项研究适合分析“观察等待”/“时间逆转”。两项研究直接比较了“时间逆转”和“非时间逆转”的接受 DOAC 治疗的髋部骨折患者（58 例“时间逆转”，62 例“非时间逆转”）。我们从另外 12 项研究中使用间接比较了“时间逆转”和“非时间逆转”的 DOAC 患者（总共 357 例“时间逆转”，282 例“非时间逆转”）。我们没有发现“时间逆转”和“非时间逆转”之间在死亡率结果上存在统计学上的显著差异（OR 1.48[95%CI：0.29-7.53]）。我们也没有发现“时间逆转”和“非时间逆转”在输血需求方面存在统计学上的显著差异（OR 1.16[95%CI 0.42-3.23]）。然而，一些作者描述说，手术延迟与延长住院时间相关的预后较差有关，并且在 36 小时内进行手术是安全的。
我们建议不要在髋部骨折中“观察等待”来逆转 DOAC 的作用。需要进一步研究以评估手术的最佳时机，以及在接受 DOAC 治疗的髋部骨折患者中使用血浆制品或特定解毒剂。
