Audit of patients taking antithrombotic medication admitted with a fracture of the neck of femur

1
Audit of patients taking antithrombotic
medication admitted with a fracture of the neck
of femur

• H. Phillips, W. Carlino, I. Chakrabarti, F.
  Al-Modaris
• Rotherham General Hospital

2
Introduction

• Patients with hip fractures should be operated on
  within 24 hours
• Delay of more than 4 days to theatre associated
  with increased inpatient mortality
• Elective patients stop clopidogrel 7 days
  before, aspirin 5 days before, warfarin INR
  less than 2.
• No clear consensus on when aspirin/clopidogrel
  should be stopped in the acute trauma setting
  prior to hip fracture surgery.

3
Aims of audit

• Evaluate proportion of patients admitted with hip
  fracture taking aspirin, clopidogrel or warfarin.
• Assess to see any delay in patients going to
  theatre.
• Correlation between these patients going back to
  theatre, post-operative morbidity and mortality
  and length of inpatient stay.

4
Patients and methods

• Retrospective audit
• 100 patients admitted between December 2006 and
  July 2007.
• Case notes identified
• Clerking sheets, hip fracture pathways and drug
  charts reviewed.

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Data collected

• Whether taking aspirin, clopidogrel, warfarin
• Co-morbidities
• How many days before surgery antithrombotic
  stopped
• ? INR reversal
• Operation
• Days from admission to theatre
• Return to theatre and why
• Post-op complications
• Number of days until discharge
• Level of mobility on admission and discharge
• Where patient admitted from and discharged to
• Mortality data

6
Gender distribution
7
Age distribution
8
Antithrombotic Medication
9
Co-morbidities
10
Number of co-morbidities
11
Operated?
12
Operation
13
When was antithrombotic therapy stopped?
14
Number of patients operated within 24 hours
15
Number of patients operated within 4 days
16
Number of days after admission to theatre
17
Patients taken back to theatre

• 92 male with cerebrovascular disease taking
  aspirin.
• DHS same day.
• Haematoma left thigh.
• Died of pneumonia.
• 96 female with cerebrovascular disease taking
  aspirin .
• Thomsons hemiarthroplasty next day.
• Wound debridement and washout of abscess.
• Died of bronchopneumonia.
• 94 female with hypertension taking aspirin .
• Thomsons hemiarthroplasty next day.
• Relocation of dislocated hip prosthesis,
  unsuccessful therefore girdlestone
• Died of ischaemic heart disease.

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Patients taking warfarin
19
Post op complications
20
Mortality
21
Mortality no antithrombotic
Aspirin/Clopidogrel
22
Mortality - aspirin
23
Admitted from?
24
Discharged to?
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Length of inpatient stay

• Aspirin 22.48 days
• Aspirin/clopidogrel 50 days
• Clopidogrel 66 days
• Warfarin 24.33 days
• No antithrombotic 24.81 days

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Conclusions

• Large proportion patients (53) with hip fracture
  taking antithrombotic medication
• Increase in delay to theatre if patients on
  aspirin
• 1 patient taking aspirin returned to theatre for
  haematoma
• Main post-operative complication was pneumonia
  no correlation to antithrombotic medication
• Patients taking aspirin may have been at
  increased risk of intra-operative blood loss
  requiring blood transfusion
• Taking aspirin may have cardio-protective
  mechanism, therefore in balance, maybe operation
  should not be delayed by witholding it
• Main causes for mortality were IHD and pneumonia.
  None related to bleeding disorder.

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Recommendations

• Aspirin should not be stopped prior to day of
  operation. (Data too small to comment on when
  clopidogrel and warfarin should be stopped).
• More patients with hip fractures should be
  operated on within the 24 hour guidelines, if
  medically fit to do so.

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References

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  delay in operation after hip fracture
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• 2 Cahill RA, McGreal GT, Crowe BH, Ryan DA,
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  increased bleeding tendency after cessation of
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  Of Surgeons 2005. 200/4 564-73
• 2 Choudhary AK, Bangalore C, Bijoor M, Kasis A.
  Warfarin affecting the outcome in patients with
  fracture neck of femur. Journal of Bone and Joint
  Surgery, British Volume 2006 88-B Issue SUPP_II
  273
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• 7 Tharmarajah P, Pusey J, Keeling D, Willett K.
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Thankyou