抗凝治疗的髋部骨折患者行加速手术方案的安全性：系统评价和荟萃分析。
Safety of expedited-surgery protocols in anticoagulant-treated patients with hip fracture: a systematic review and meta-analysis.
机构信息
From the Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alta. (You, Korley, Schneider); the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alta. (You, Korley, Schneider); the Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ont. (Xu, Carrier); and the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Krzyzaniak).
From the Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alta. (You, Korley, Schneider); the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alta. (You, Korley, Schneider); the Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ont. (Xu, Carrier); and the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Krzyzaniak)
出版信息
Can J Surg. 2023 Mar 31;66(2):E170-E180. doi: 10.1503/cjs.010021. Print 2023 Mar-Apr.
BACKGROUND
Perioperative management of patients with hip fracture patients receiving oral anticoagulants requires navigating the risks associated with surgical delay and perioperative hemostasis. The aim of this systematic review and meta-analysis was to evaluate the effect of expedited-surgery protocols on time to surgery and perioperative outcomes in anticoagulant-treated patients with hip fracture.
METHODS
We searched MEDLINE, Embase and CENTRAL from inception to May 5, 2020, to identify English-language studies reporting outcomes after expedited hip fracture surgery in patients receiving vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) before hospital admission. We performed a meta-analysis using Mantel-Haenszel weighting for dichotomous variables and inverse variance weighting for continuous variables.
RESULTS
Among the 4253 citations identified, 14 studies were included. In the 6 studies eligible for meta-analysis, compared to hip fracture surgery before implementation of a VKA-reversal protocol, surgery after implementation of such a protocol was associated with a significant reduction in time to surgery (mean difference 45.31 h, 95% confidence interval [CI] 15.81 h to 74.80 h). Expedited surgery (within 48 h) in patients who received DOACs preoperatively was not associated with increased surgical duration (mean difference -7.29 min, 95% CI -22.5 min to 7.95 min) or 30-day mortality (odds ratio [OR] 1.30, 95% CI 0.49 to 3.89) compared to patients who did not receive anticoagulants (control patients). However, expedited surgery in DOAC-treated patients was associated with an increased blood transfusion risk compared to control patients (OR 0.58, 95% CI 0.36 to 0.96).
CONCLUSION
Implementing a VKA-reversal protocol for patients with hip fracture is effective in decreasing time to surgery, without an increased bleeding risk. Performing hip fracture surgery within 48 hours in DOAC-treated patients is also safe, with a small increase in blood transfusion risk.
背景
接受口服抗凝剂治疗的髋部骨折患者的围手术期管理需要权衡手术延迟和围手术期止血的风险。本系统评价和荟萃分析的目的是评估在接受维生素 K 拮抗剂（VKA）或直接口服抗凝剂（DOAC）治疗的髋部骨折患者中，加速手术方案对手术时间和围手术期结果的影响。
方法
我们检索了 MEDLINE、Embase 和 CENTRAL 从成立到 2020 年 5 月 5 日，以确定报告在入院前接受维生素 K 拮抗剂（VKAs）或直接口服抗凝剂（DOACs）治疗的患者接受髋部骨折手术后加速髋部骨折手术结果的英语研究。我们使用 Mantel-Haenszel 加权法对二分类变量和Inverse Variance 加权法对连续变量进行荟萃分析。
结果
在 4253 篇引文识别出的 14 项研究中，有 14 项研究被纳入。在 6 项符合荟萃分析条件的研究中，与实施 VKA 逆转方案前的髋部骨折手术相比，实施该方案后的手术时间明显缩短（平均差异 45.31 小时，95%置信区间 [CI] 15.81 小时至 74.80 小时）。在术前接受 DOAC 治疗的患者中，在 48 小时内进行紧急手术（48 小时内）与手术持续时间增加无关（平均差异-7.29 分钟，95%置信区间-22.5 分钟至 7.95 分钟）或 30 天死亡率（比值比 [OR] 1.30，95%置信区间 0.49 至 3.89）与未接受抗凝剂（对照组）的患者相比。然而，与对照组相比，DOAC 治疗患者的紧急手术与输血风险增加相关（OR 0.58，95%CI 0.36 至 0.96）。
结论
为髋部骨折患者实施 VKA 逆转方案可有效缩短手术时间，且不增加出血风险。在 DOAC 治疗的患者中，在 48 小时内进行髋部骨折手术也是安全的，输血风险略有增加。
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