Surgical Delay in Acute Admissions on Warfarin
Surgical Delay in Acute Admissions on Warfarin
Warfarin anti-coagulation can cause significant delay in acute surgical admissions. We reviewed fracture neck of femur patients operated over a period of 4 years in our unit. There was an average delay to surgery of 4.36 days in patients on warfarin as against an average delay of 1.78 days in patients not on warfarin (p < 0.001). The review was followed up with a questionnaire-based survey of consultant haematologists, and a general agreement towards a protocol-based use of vitamin K1 was noted. The reasons for limited use of vitamin K1 include the lack of studies and guidelines specifically addressing the pre-operative emergency admissions. We highlight a practical problem shared across different specialities and identify the areas for future studies.
The use of vitamin K1 for the reversal of anti-coagulant effect of warfarin has been studied extensively in patients attending anti-coagulation clinics. There are guidelines from the American College of Chest Physicians for the use of vitamin K1 in anti-coagulation clinics in patients with excessive warfarin-induced anti-coagulation. These favour the use of vitamin K1 rather than accept the risk of bleeding if the international normalised ratio (INR) is more than 5.0. There has been a trend of using vitamin K1 more often, in keeping with these recommendations. However, there have been no efforts to assess current practices and establish similar guidelines in patients being deferred surgical management because of their anti-coagulation therapy.
There are two options available for the reversal of warfarin anti-coagulation prior to undertaking any major surgery. The patients for elective surgery are often weaned off the anti-coagulation by stopping warfarin 4-5 days prior to admission. The other option is active reversal using vitamin K1, fresh frozen plasma, clotting factor concentrates or a combination of these. The use of fresh frozen plasma and the clotting factor concentrates is limited, as they are expensive and have the risks associated with the transfusion of blood products. They have a role to play in situations demanding immediate correction and are not discussed any further in this study.
The decision to wait or actively reverse warfarin anti-coagulation is often not easy, as there is a spectrum of 'semi-emergencies' in between the elective surgeries and the life-threatening emergencies. If warfarin therapy is stopped, it takes about 4 days for the INR to drop to values acceptable for surgical management. If vitamin K1 is given, depending on the route and dose used, this duration could be reduced to 12-24 h. Any patient who could wait for 12-24 h and would benefit from surgery in less than 4 days is a potential candidate for reversal using vitamin K1 therapy.
We, in our study, aim at assessing the current practice and the concerns associated with the use of vitamin K1 in patients with warfarin-induced coagulopathy awaiting surgery. We chose to study the fracture neck of femur patients on warfarin, as they are one of the more common of the emergency admissions that almost always necessitate surgery and that a delay in their management does lead to increased morbidity and, potentially, increased mortality.
Warfarin anti-coagulation can cause significant delay in acute surgical admissions. We reviewed fracture neck of femur patients operated over a period of 4 years in our unit. There was an average delay to surgery of 4.36 days in patients on warfarin as against an average delay of 1.78 days in patients not on warfarin (p < 0.001). The review was followed up with a questionnaire-based survey of consultant haematologists, and a general agreement towards a protocol-based use of vitamin K1 was noted. The reasons for limited use of vitamin K1 include the lack of studies and guidelines specifically addressing the pre-operative emergency admissions. We highlight a practical problem shared across different specialities and identify the areas for future studies.
The use of vitamin K1 for the reversal of anti-coagulant effect of warfarin has been studied extensively in patients attending anti-coagulation clinics. There are guidelines from the American College of Chest Physicians for the use of vitamin K1 in anti-coagulation clinics in patients with excessive warfarin-induced anti-coagulation. These favour the use of vitamin K1 rather than accept the risk of bleeding if the international normalised ratio (INR) is more than 5.0. There has been a trend of using vitamin K1 more often, in keeping with these recommendations. However, there have been no efforts to assess current practices and establish similar guidelines in patients being deferred surgical management because of their anti-coagulation therapy.
There are two options available for the reversal of warfarin anti-coagulation prior to undertaking any major surgery. The patients for elective surgery are often weaned off the anti-coagulation by stopping warfarin 4-5 days prior to admission. The other option is active reversal using vitamin K1, fresh frozen plasma, clotting factor concentrates or a combination of these. The use of fresh frozen plasma and the clotting factor concentrates is limited, as they are expensive and have the risks associated with the transfusion of blood products. They have a role to play in situations demanding immediate correction and are not discussed any further in this study.
The decision to wait or actively reverse warfarin anti-coagulation is often not easy, as there is a spectrum of 'semi-emergencies' in between the elective surgeries and the life-threatening emergencies. If warfarin therapy is stopped, it takes about 4 days for the INR to drop to values acceptable for surgical management. If vitamin K1 is given, depending on the route and dose used, this duration could be reduced to 12-24 h. Any patient who could wait for 12-24 h and would benefit from surgery in less than 4 days is a potential candidate for reversal using vitamin K1 therapy.
We, in our study, aim at assessing the current practice and the concerns associated with the use of vitamin K1 in patients with warfarin-induced coagulopathy awaiting surgery. We chose to study the fracture neck of femur patients on warfarin, as they are one of the more common of the emergency admissions that almost always necessitate surgery and that a delay in their management does lead to increased morbidity and, potentially, increased mortality.