Anaesthesia 2014, 69, 511–526

Prothrombin complex concentrate reversal of warfarin in patients with hip fracture Increasingly, evidence suggests that earlier surgery for hip fracture results in fewer complications and reduced in-hospital lengths of stay, promoting more dynamic management of this high-risk patient group [1]. Research has shown that for every eight-hour delay to surgery beyond 48 hours, patients will spend an additional 24 hours in hospital postoperatively [2]. Within our institution, a recent audit of one year’s practice identified that of nine patients who’d had hip fracture surgery delayed because they were medically unfit (according to McLaughlin et al.’s ‘major’ criteria [3]), six (67%) had their surgery postponed because of delayed reversal of a therapeutically raised international normalised ratio (INR). Management plans for reversal of warfarin were not standardised, and ranged from conservative observation to use of vitamin K, the median (IQR [range]) time for reversal of INR < 1.5 being 43 (36–52 [30–70]) h, resulting in a median (IQR [range]) delay to theatre of 76 (57–84 [36–91]) h. Prothrombin complex concentrates (PCCs) are an expensive treatment option reserved for specific patient groups, including cases of major haemorrhage with coagulopathy [4]. Following administration of PCC, coagulopathy normally corrects within 30 minutes, lasting for at least six hours; coadministration of vitamin K is thought to prevent rebound increases in INR and provide sus520

Correspondence

Table 1 Relative costs of treating a 70-kg patient with a hip fracture and a therapeutic INR of 3, with and without PCC treatment. No PCC used Median delay to theatre for warfarin reversal; h Cost of reversal (inpatient bed) Cost of reversal (PCC) Calculated additional postoperative stay; days Calculated additional inpatient bed cost Overall additional cost

76

J. Francis G. Girish R. Jones Royal Glamorgan Hospital, Llantrisant, UK Email: [email protected]

< 0.5

£855 (€1024; $1410) 0 3.5 £945 (€1132; $1559) £1800 (€2156; $2969)

tained reversal of anticoagulation [5]. Based on our median INR reversal time and related delay to theatre, we modelled whether PCC is a costeffective way to manage warfarinised patients presenting with hip fracture (Table 1). The cost of a single dose of PCC (Beriplexâ P/N, CSL Behring UK Ltd, Haywards Heath, West Sussex, UK) for an average 70-kg patient is £550 [4], and of an inpatient bed day, £270 [6]. Our calculations suggest a saving of £1250 per patient with hip fracture using PCC for reversal of warfarin. Recent research supports both economic and clinical benefits from using PCC in the emergency setting, with fewer adverse events experienced with PCCs than with fresh frozen plasma [7, 8]. We are now implementing a PCC-based warfarin reversal protocol for patients with hip fracture, which should cost-effectively allow us to expedite surgery and so improve patient outcome.

PCC used

0 £550 (€658; $916) 0 0 £550 (€658; $916)

No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.

References 1. Association of Anaeasthetists of Great Britain and Ireland. Management of proximal femoral fractures 2011. Anaesthesia 2012; 67: 85–98. 2. Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. International Journal for Quality in Health Care 2007; 19: 170–6. 3. McLaughlin MA, Orosz GM, Magaziner J, et al. Preoperative status and risk of complications in patients with hip fracture. Journal of General Internal Medicine 2006; 21: 219–22. 4. Bhardwaj M, Bunsell R. Beriplex P/N: an alternative to fresh frozen plasma in severe haemorrhage. Anaesthesia 2007; 62: 832–4. 5. Patanwala AE, Acquisto NM, Erstad BL. Prothrombin complex concentrate for critical bleeding. Annals of Pharmacotherapy 2011; 45: 990–9. 6. Department of Health. Reference Costs 2011 – 2012. Published 8th November 2012. https://www.gov.uk/government/ publications/nhs-reference-costs-financialyear-2011-to-2012 (accessed 19/03/ 2014). 7. Hickey M, Gatien M, Taljaard M, Aujnarain A, Giulivi A, Perry JJ. Outcomes of urgent warfarin reversal with frozen plasma versus prothrombin complex concentrate in the emergency department. Circulation 2013; 128: 360–4. 8. Guest JF, Watson HG, Limaye S. Modeling the cost-effectiveness of prothrombin

© 2014 The Association of Anaesthetists of Great Britain and Ireland

Correspondence

Anaesthesia 2014, 69, 511–526

complex concentrate compared with fresh frozen plasma in emergency warfarin reversal in the United Kingdom. Clinical Therapeutics 2010; 32: 2478– 93. doi:10.1111/anae.12702

Three-dimensional interactive model of lumbar spinal structures The application of three-dimensional software to pre-operative magnetic resonance imaging (MRI) data [1] enables 3D models to be reconstructed and embedded in Portable Document Format (PDF) files [2, 3]. We wish to bring readers’ attention to a free resource for 3D MRI images that might be useful for interactive demonstration of lumbosacral structures, specifically relevant to neuraxial blockade: http://

diposit.ub.edu/dspace/handle/2445/4 4844?locale=en (English translation top right of screen). At present, this program runs under Acrobat Reader XI on Windows or Mac computers, but not on tablets, smartphones or Linux systems. Files must be downloaded and saved in the same folder, for which the name must not contain spaces or special characters. Source code and model geometry are not public. The model includes reconstructions of vertebrae, intervertebral disks, ligaments, epidural and foraminal fat, dural sac and sleeves, sensory and motor cauda equina roots, anaesthetic approaches (epidural medial, spinal paramedical and radicular paths), together with predefined sequential 3D views of anaesthetic approaches to epidural blockade, for educational purposes. Zoom, 360° rotation, selective views

and transparencies of each structure, and clipping functions, are available (Fig. 4). A. Prats-Galino M. Mavar Faculty of Medicine, Universitat de Barcelona Barcelona, Spain Email: [email protected] M. A. Reina Madrid-Monteprıncipe University Hospital Madrid, Spain A. Puigdellıvol-Sanchez Universitat de Barcelona and Consorci Sanitari de Terrassa Rubı (Barcelona), Spain J. San-Molina University of Girona Girona, Spain J. A. De Andres General University Hospital Valencia, Spain The project was partially funded by Marato TV3 Grant Project 411/U/ 2011. Ethical committee approval was obtained for the use of anonymised DICOM-MRI data (Code CEIC-Grupo HM: 13.03.433-GHM). No competing interests declared.

References

Figure 4 3D interface: 1) screen working area; 2) different aspects available; 3) list of structures, with 4) check box confirmation; 5) arrows to modify transparency; 6) command to combine or 7) hide structures; 8) selection of views with 9) navigation tools; 10) clipping tool in 11) three planes and 12) different cuts in each plane; 13) predefined educational views; 14) disabled automatic selection of clicked structures; 15) help file. © 2014 The Association of Anaesthetists of Great Britain and Ireland

1. BWH and 3D slicer contributors. 3D slicer, 2014. https://www.slicer.org/pages/ Introduction (accessed 06/03/2014). 2. Phelps A, Naeger DM, Marcovici P. Embedding 3D radiology models in portable document format. American Journal of Roentgenology 2012; 199: 1342–4. 3. Mavar-Haramija M, Prats-Galino A, Berenguer-Escuder Cl, Juanes-Mendez JA, Puigdellívol-Sanchez A. 3D PDF Technology combined with JavaScript function enables the creation and visualization of interactive 3D presentations. ACM Digital Library. http://dl.acm.org/citation.cfm? id=2536548 (accessed 06/03/2014). doi:10.1111/anae.12690

521

Prothrombin complex concentrate reversal of warfarin in patients with hip fracture.

Prothrombin complex concentrate reversal of warfarin in patients with hip fracture. - PDF Download Free
111KB Sizes 0 Downloads 3 Views