Anaesthesia 2024 doi:10.1111/anae.

16226

Guidelines

Principles for management of hip fracture for older adults

taking direct oral anticoagulants: an international
consensus statement
R. J. Mitchell,1 S. Wijekulasuriya,2 A. Mayor,3 F. K. Borges,4 A. C. Tonelli,4,5 J. Ahn6 and
H. Seymour7 on behalf of the Fragility Fracture Network Hip Fracture Audit Special
Interest Group

1 Associate Professor, 2 Research Assistant, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW,
Australia
3 Consultant Anaesthetist, Department of Anaesthesia, Huddersfield Royal Infirmary, Huddersfield, UK
4 Assistant Professor, Department of Medicine, McMaster University, Hamilton, ON, Canada
5 Physician, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
6 Professor, Department of Orthopaedic Surgery and Biomedical Engineering, University of Michigan, Ann Arbour,
MI, USA
7 Consultant, Department of Geriatric Medicine, Fiona Stanley Fremantle Hospitals Group, Perth, WA, Australia

Summary
Hip fracture is a common serious injury among older adults, yet the management of hip fractures for
patients taking direct oral anticoagulants remains inconsistent worldwide. Drawing from a synthesis of
available evidence and expert opinion, best practice approaches for managing patients with a hip
fracture and who are taking direct oral anticoagulants pre-operatively were considered by a working
group of the Fragility Fracture Network Hip Fracture Audit Special Interest Group. The literature and
related clinical guidelines were reviewed and a two-round modified Delphi study was conducted with a
panel of experts from 16 countries and involved seven clinical specialities. Four consensus statements
were achieved: peripheral nerve blocks can reasonably be performed on presentation for patients with
hip fracture who are receiving direct oral anticoagulants; hip fracture surgery can reasonably be
performed for patients taking direct oral anticoagulants < 36 h from last dose; general anaesthesia could
reasonably be administered for patients with hip fracture and who are taking direct oral anticoagulants
< 36 h from last dose (assuming eGFR > 60 ml.min-1.1.73 m-2); and it is generally reasonable to consider
recommencing direct oral anticoagulants (considering blood loss and haemoglobin) < 48 h after hip
fracture surgery. No consensus was achieved regarding timing of spinal anaesthesia. The consensus
statements were developed to aid clinicians in their decision-making and to reduce practice variations in
the management of patients with hip fracture and who are taking direct oral anticoagulants. Each
statement will need to be considered specific to each individual patient’s treatment.

.................................................................................................................................................................
Correspondence to: H. Seymour
Email: [email protected]
Accepted: 4 December 2023
Keywords: DOAC; guidelines; hip fracture; surgery

.................................................................................................................................................................
Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not permit
commercial exploitation.

© 2024 Association of Anaesthetists. 1

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia 2024 Mitchell et al. | Hip fracture management consensus for patients on DOACs

Presented in part at the 11th Fragility Fracture Network Global Congress, 4-6 October 2023 (Oslo, Norway).
Twitter/X: @HealthDataProf; @HannahS93001953

Recommendations best practice approaches for managing patients with hip

1 Peripheral nerve blocks can reasonably be performed fracture who are taking DOACs pre-operatively. The
on presentation for patients with hip fracture who are consensus statement aims to contribute to improving the
receiving direct oral anticoagulants (DOACs). health-related quality of life (HRQoL) of older adults after hip
2 Hip fracture surgery can reasonably be performed for fracture and healthy ageing post-fracture. The consensus
patients who were taking DOACs within 36 h from last statement was developed based on the principles of
dose. collaborative involvement across multidisciplinary teams.
3 General anaesthesia could reasonably be administered
for hip fracture surgery in patients who were taking How and why does this statement differ
DOACs < 36 h from last dose (assuming `normal´ renal from existing guidelines?
function, i.e. eGFR > 60 ml.min-1.1.73 m-2). Around two- Previous guideline statements that considered DOACs did
thirds of panellists also agreed that general anaesthesia not consider all peri-operative aspects of hip fracture
could reasonably be administered < 24 h from last treatment addressed here [1] or were not specific to hip
DOAC dose (based on moderate consensus). fracture [2–7]. This consensus statement promotes a
4 It is generally reasonable to consider recommencing standardised approach to treatment for patients with hip
DOACs (considering blood loss and haemoglobin) fracture taking DOACs, facilitating the best possible health
within 48 h of hip fracture surgery. outcomes across the globe.

What other guideline statements are Introduction

available on this topic? As the worldwide population ages, the number of fall-related
There are several guidelines that consider the management hip fractures among older adults is increasing and is
of DOACs around the time of anaesthesia and surgery, estimated to rise to 6.26 million by 2050 [8]. A fractured hip is
including the Guideline for the management of hip fractures one of the most serious fall-related injuries for an older adult,
[1]; American Society of Regional Anesthesia and Pain as it can reduce mobility, independence and overall quality of
Medicine regional anaesthesia in patients receiving life [9]. Many factors can affect recovery and return to mobility
antithrombotic or thrombolytic therapy guidelines [2]; after a hip fracture, but hip fracture surgery within 1 or 2 days
European Heart Rhythm Association practice guide on the use of admission has been shown to be an important contributor
of non-vitamin K antagonist oral anticoagulants in patients to a lower risk of mortality [10, 11], complications and hospital
with atrial fibrillation [3]; Interventional spine and pain duration of stay [12–16]. Hip fracture clinical care guidelines
procedures in patients on antiplatelet and anticoagulant generally advocate hip fracture surgery within 24–48 h of
medications [4] representing guidelines from the American hospital admission [17–19].
Society of Regional Anesthesia and Pain Medicine, European As the number of older adults increases, the incidence
Society of Regional Anaesthesia and Pain Therapy, American of morbidity and mortality from thrombotic disorders or
Academy of Pain Medicine, International Neuromodulation atrial fibrillation, such as stroke or myocardial infarction, is
Society, North American Neuromodulation Society and also rising [20]. These arterial and venous thromboembolic
World Institute of Pain; Perioperative management of disorders are increasingly being managed with DOACs [20,
antithrombotic therapy: an American College of Chest 21], due to ease of administration and, unlike vitamin K
Physicians clinical practice guideline [5]; and antagonists, they do not require regular monitoring [22].
Recommendations from the International Consensus Since 2017, the dispensing of DOACs has surpassed
Meeting: Venous thromboembolism (ICM-VTE): Trauma [6]. warfarin in the USA and UK [23, 24]. Considering that most
people taking DOACs are aged ≥ 65 y [23] and up to 40% of
Why were these consensus statements patients with a hip fracture are taking anticoagulation [25],
developed? not having a reversible drug available for DOACs (except
The purpose of the consensus statement is to draw from a dabigatran) may influence the management following hip
synthesis of available evidence, and from expert opinion, fracture. For some older adults taking a DOAC, a delay in

2 © 2024 Association of Anaesthetists.

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Mitchell et al. | Hip fracture management consensus for patients on DOACs Anaesthesia 2024

performing hip fracture surgery to allow medical core set of 10 themes and questions regarding the
optimisation may be necessary to reduce intra- and management of patients with a hip fracture taking DOACs
postoperative blood loss [26] and to deliver safe regional (online Supporting Information Appendix S1, Table S1).
anaesthesia [27]. However, currently, there is an absence of Delegates at the FFN Congress in October 2022 who
consensus regarding the management of patients with a hip attended an interactive workshop on hip fracture care and
fracture taking DOACs [3, 22, 28–30], with conflicting DOACs responded to the questions and provided their
evidence as to whether delaying surgery provides a health opinions on the management of patients with a hip fracture
benefit [31]. taking DOACs during the workshop. The responses of the
For this consensus statement, DOACs refer to a class of workshop attendees (online Supporting Information
oral anticoagulants that directly inhibit a single target and Appendix S1, Figures S1–S10) were used to inform a two-
have similar clinical properties (e.g. rivaroxaban; apixaban; round modified Delphi study.
edoxaban; betrixaban; and dabigatran). The mechanism of A total of 111 international experts who were clinicians
action of either factor Xa inhibitors (i.e. rivaroxaban; experienced in managing patients with a hip fracture were
apixaban; edoxaban; and betrixaban) or direct thrombin identified from a range of sources, including the FFN,
inhibitors (i.e. dabigatran) is used when it is clinically professional associations and professional networks of
important to distinguish between the DOAC medications. clinicians who manage patients with hip fracture and were
invited to join a panel and participate in a two-round modified
Methods Delphi study. Participation was voluntary and anonymous.
This consensus statement development was guided by the Experts were also able to forward the survey link to colleagues
Fragility Fracture Network (FFN) Hip Fracture Audit Special involved in hip fracture care management. The modified
Interest Group which convened a hip fracture and DOAC Delphi study was conducted during 2023 and was used to
working group. The working group piloted a series of identify where there was (and was not) consensus on the
questions related to hip fracture treatment and DOACs at an themes and statements relating to the management of
interactive workshop at the 2022 FFN Global Congress in patients with a hip fracture taking DOACs pre-operatively, an
Melbourne, Australia. A two-round modified Delphi study approach adopted by WikiGuidelines [34].
with an international group of experts was then conducted to In stage 1, the modified Delphi consisted of 10 themes
identify where there was (and was not) consensus on the and 20 questions, and panellists were asked to select a
management of patients with hip fracture taking DOACs. response from a list of choices that most corresponded with
The consensus document was then finalised with a virtual their opinion regarding the clinical management of patients
workshop involving the hip fracture and DOAC working with a hip fracture and who were taking DOACs. Panellists
group and presentation at an interactive workshop regarding were also provided with an option to include the key factors
the consensus statements at the FFN Global Congress in that led to their selection and to provide any further
Oslo, Norway, in October 2023. Ethical approval was comments. A threshold of eGFR > 60 ml.min-1.1.73 m-2 was
obtained from the Macquarie University Ethics Committee. used for the modified Delphi survey to represent patients
The FFN includes health professionals and other who would have adequate function to clear a DOAC [35].
stakeholders with an interest in reducing the burden of Stage 1 was designed to obtain feedback regarding the
fragility fractures and enhancing care quality for patients. management of patients with a hip fracture taking DOACs
The hip fracture and DOAC working group included experts and was conducted during March–April 2023. Sixty-one
from a range of backgrounds who had either authored experts completed stage 1 (36%) and 21 additional experts
publications on hip fracture and DOAC use and/or were provided responses. Panellists worked across 16 countries
involved in the development of clinical guidelines or and seven specialities (online Supporting Information
protocols related to hip fracture care and/or were directly Appendix S2).
involved in the peri-operative management of patients with During stage 2, feedback was provided to the expert
a hip fracture. The specialities represented on the hip panellists from stage 1 in the form of a summary of
fracture and DOAC working group included: geriatrics; responses to the stage 1 questions and the relevant
orthopaedics; orthogeriatrics; anaesthesia; internal literature. In stage 2, the modified Delphi consisted of three
medicine; peri-operative medicine; and epidemiology. themes and 22 questions. Panellists were asked to provide a
The hip fracture and DOAC working group, informed response from a list of choices that most corresponded with
by systematic reviews [31, 32], literature reviews [28, 29] and their opinion regarding the clinical management of patients
related clinical practice guidelines [1, 3, 5, 33], developed a with a hip fracture taking DOACs. Panellists were provided

© 2024 Association of Anaesthetists. 3

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia 2024 Mitchell et al. | Hip fracture management consensus for patients on DOACs

with an option to include key factors that led to their Question 1: For patients who present with a hip fracture
selection and to provide any further comments. Forty-four and are receiving a DOAC should a peripheral nerve
experts completed stage 2 (72%) (online Supporting block be performed on presentation?
Information Appendix S3). There was not enough evidence to indicate the best time
At the conclusion of stage 2, a summary of the panel interval between the last dose of a DOAC and a
responses was provided to the hip fracture and DOAC peripheral nerve block for patients with a hip fracture.
working group and it reviewed the panel consensus on each There was one prospective pilot study of 69 patients
question and the commentary regarding their selection. taking apixaban or rivaroxaban presenting to a regional
Consensus among panellists was identified a priori and was trauma centre in Israel: 19 patients were treated with an
considered to be high, moderate or low when the proportion ultrasound-guided femoral nerve blockade and 50 were
of all ratings was ≥ 70%, 50–69% and < 50%, respectively treated with conventional analgesics [37]. There was no
[36]. High to moderate consensus were considered significant difference between the nerve block and
acceptable to make consensus statements regarding the care conventional analgesia in the number of major bleeding
of patients with a hip fracture taking DOACs. While panel events (47% vs. 54%); blood transfusion rates (26% vs.
consensus was reported for each question, the rationale and 20%); change in haemoglobin levels compared with
all pros and cons reported by the panellists were considered baseline (2.2 mg.dl-1 vs. 1.9 mg.dl-1); hospital duration of
as these statements may relate to practising in different stay (6 days vs. 6 days); rate of re-operation (0% vs. 0%);
clinical, geographical and resourced environments. wound hematomas (0% vs. 0%); wound infection (11% vs.
To finalise the consensus statements, virtual discussion 6%); delirium (26% vs. 22%); sepsis (5% vs. 14%) or 30-
took place during July 2023 with the hip fracture and DOAC day mortality (5% vs. 12%) [37].
working group members to discuss panellist responses to There was high consensus (n = 31, 70.5%) among
each question. The consensus statements were then panellists that a peripheral nerve block could be reasonably
presented for discussion and finalisation at an interactive performed on presentation for patients with hip fracture
workshop at the FFN Global Congress in October 2023 in who were receiving a factor Xa inhibitor. There was
Norway (online Supporting Information Appendix S4). The moderate consensus (n = 26, 59%) for performing a
consensus statements, their methods and the results of each peripheral nerve block on presentation when a patient was
development stage, along with the supplementary material receiving a direct thrombin inhibitor.
was reviewed and supported by the WikiGuidelines
steering group as being consistent with the WikiGuidlines Consensus statement 1: Peripheral nerve blocks can
charter guidelines principles [34]. reasonably be performed on presentation for patients
with a hip fracture who are receiving a DOAC.
Results
The panellists from stages 1 and 2 of the modified Delphi This consensus statement considered the potential risks of
study responded to nine questions regarding the bleeding after administering a peripheral nerve block weighed
management of patients with a hip fracture taking DOACs against the potential risk of uncontrolled pain or adverse
during four phases of care: presentation (nerve block); pre- effects of opioid analgesia [7]. By administering a peripheral
operative (timing of surgery); intra-operative care nerve block early, there is a theoretical increased risk of
(anaesthesia); and postoperative (recommencing DOACs). bleeding. However, this risk is likely to be small and needs to
There was insufficient evidence from published research to be weighed against the benefits of a nerve block which are
provide definitive evidence-based statements for each proven to reduce pain on movement within 30 min of block
management principle. The available evidence is placement, risk of delirium and probably also reduce the risk of
summarised and the majority opinion of the panellists pulmonary infection and time to first mobilisation [38].
is provided as the consensus approach. Any areas of
contention regarding the consensus principle identified by Question 2: For inpatients who require hip fracture
panellists were recorded and summarised (online surgery and were receiving a DOAC, how long from last
Supporting Information Appendix S5, Table S8). dose should surgery be delayed?
Recommendations from existing guidelines either explicit There was no evidence to indicate if hip fracture surgery for
for hip fracture management or surgical care for patients patients taking DOACs could reasonably be delayed,
taking DOACs are summarised in online Supporting including for different types of hip fracture surgery. Sixteen
Information Appendix S6, Table S9. retrospective cohort [22, 39–53] and four case–control

4 © 2024 Association of Anaesthetists.

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Mitchell et al. | Hip fracture management consensus for patients on DOACs Anaesthesia 2024

studies [54–57] report the type of hip fracture surgery red cell transfusion rates were 24%, 40% and 27%,
performed for patients taking DOACs. respectively.
In a retrospective cohort study of the Danish In a retrospective cohort study of 755 patients with a
Multidisciplinary Hip Fracture Registry (103,299 patients hip fracture, Goh et al. identified no significant
with a hip fracture, n = 1063 taking DOACs), there were no differences in incidence of venous thromboembolism for
significant differences in all-cause 30-day mortality for patients taking DOACs who had surgery < 24 h and
patients taking DOACs compared with patients taking ≥ 24 h compared with standard care with low-molecular-
vitamin K antagonists or antiplatelet drug (11.3% vs. 10.8% weight heparin (LMWH) (0% vs. 1.2% vs. 1.3%,
vs. 12.7%, respectively) (hazard ratio 0.88, 95%CI 0.75–1.03) respectively; p = 0.94) [53]. There was also no significant
[25]. For patients taking DOACs and who had surgery difference in all-cause 30-day mortality.
> 36 h after last dose, the adjusted hazard ratio indicated Considering the type of hip fracture surgery, a
no detrimental effect (0.70, 95%CI 0.54–0.91) [25]. Similarly, retrospective cohort study of 320 patients having hip
Krespi et al. performed a retrospective cohort study of 171 fracture surgery (n = 54 taking DOACs), found that when
patients with a hip fracture who underwent surgery 24 h, patients had been operated on within 24 h, blood loss
24–48 h and 48 h after last DOAC dose [47]. They found no through drainages and red blood cell transfusion were not
significant differences between groups in terms of 30-day significantly different between type of surgery (i.e. dynamic
mortality (3.1% vs. 4.3% vs. 13.0%); 90-day mortality (0% vs. hip screw, hemiarthroplasty, total hip arthroplasty or
3.2% vs. 6.5%); 90-day venous thromboembolism (0% proximal femoral nail anti-rotation) in patients taking
1
vs. 1.1% vs. 0%); haemoglobin change (3.79 g.dl vs. 3.33 DOACs or warfarin [58].
1
g.dl vs. 3.06 g.dl-1); packed red cell administration (15.6% A retrospective case–control study of 63 patients taking
vs. 14.0% vs. 13.0%); 30-day readmission (3.1% vs. 14.0% vs. DOACs and 62 patients not taking a DOAC or warfarin,
8.7%); and 90-day readmission (9.4% vs. 8.6% vs. 0%). The examined whether waiting for the elimination of a DOAC
authors suggested that surgical delay should be avoided. had an effect on the amount of peri-operative bleeding [55].
In a retrospective cohort study, Levack et al. compared An adjusted analysis of peri-operative change in
133 patients who underwent hip fracture surgery within haemoglobin concentration found that surgery which used
24 h and > 24 h of last DOAC dose, and found no a combination of sliding hip screw and intramedullary nail
significant difference in overall complications (35.1% vs. was associated with a greater haemoglobin drop compared
48.4%) or transfusion rates (37.8% vs. 45.3%) [39]. In a with the use of sliding hip screws alone. There was no
retrospective cohort study, King et al. compared 17 patients significant difference in haemoglobin concentration change
who had surgery < 48 h (early DOAC group) and 11 for hemiarthroplasty, intramedullary nail or total hip
patients who had surgery > 48 h after last DOAC dose (late replacement compared with sliding hip screws. Schermann
DOAC group) [46] with 56 patients who were not taking et al. [51], in a retrospective cohort study that included 89
DOACs and who had surgery within 48 h (non-DOAC patients using DOACs (n = 60 patients had a closed
group) [46]. There were no significant differences between reduction and internal fixation and n = 29 had
the early DOAC, non-DOAC and late DOAC groups in terms hemiarthroplasty) found time to surgery was significantly
of in-hospital mortality (0% vs. 5.4% vs. 9.1%); 30-day longer for closed reduction and internal fixation for patients
mortality (0% vs. 5.4% vs. 9.1%); or wound infection (5.9% vs. taking DOACs compared with patients who were not (mean
1.8% vs. 9.1%). There were significant differences in 90-day (SD) 40 (26.9) h vs. 31 (22.2) h, respectively). There was no
mortality between the early and late DOAC groups (0% vs. difference in time to surgery for patients who had a
36.4%, respectively), but not between the early DOAC (0%) hemiarthroplasty and were taking DOAC compared with
and non-DOAC groups (0% vs. 8.9%, respectively). The those who were not (mean (SD) 42 (27.3) h vs. 37 (25.8) h,
authors suggested that the taking of DOACs is not a reason respectively).
to delay surgery [46]. There were varied opinions among panellists
In a prospective study of 120 patients with a hip regarding patients receiving a factor Xa inhibitor and the
fracture, Aziz et al. found a significant difference in blood length of time that surgery could reasonably be delayed
transfusion rates between patients taking DOACs according from last dose. Panellists specified surgery could
to three hospital protocols: wait for 24 h from last DOAC reasonably be delayed 12–24 h (n = 16, 37%); < 12 h
dose before surgery; measure DOAC levels and proceed to (n = 13, 30%); > 24–36 h (n = 9, 21%); or > 36–48 h
surgery once below the threshold of < 50 ng.ml-1; and wait (n = 5, 11%). Overall, there was high consensus among
48 h from last DOAC dose before surgery [30]. The packed panellists (n = 38, 86%) for conducting hip fracture

© 2024 Association of Anaesthetists. 5

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia 2024 Mitchell et al. | Hip fracture management consensus for patients on DOACs

surgery within 36 h from last dose for patients who were inhibitors and 15–17 h for a direct thrombin inhibitor),
receiving a factor Xa inhibitor. In terms of considering a there would be < 25% of circulating active drug in the
time period < 36 h, there was moderate consensus plasma when conducting hip fracture surgery within 36 h
among panellists (n = 29, 66%) for conducting hip from last dose. For most patients, the benefits of early
fracture surgery within 24 h from last dose for patients hip fracture surgery are evident and well-known [28].
who were receiving a factor Xa inhibitor. There were also
varied opinions among panellists when considering Question 3: In patients who require hip fracture surgery
patients who were receiving a direct thrombin inhibitor and are receiving a DOAC, how long should a
and the length of time that surgery could reasonably be multidisciplinary team wait before giving a general
delayed from last dose. Panellists specified that surgery anaesthetic (assuming normal renal function, i.e. eGFR
could reasonably be delayed for < 12 h (n = 13, 30%); > 60 ml.min-1.1.73 m-2)?
12–24 h (n = 12, 27%); > 24–36 h (n = 9, 21%); or > 36– AND
48 h (n = 8, 18%). Overall, there was high consensus Question 4: In patients who require hip fracture surgery
among panellists (n = 34, 77.3%) for conducting hip and are receiving a DOAC, how long should a
fracture surgery within 36 h from last dose for patients multidisciplinary team wait before giving a spinal
who were receiving a direct thrombin inhibitor. In terms anaesthetic (assuming normal renal function, i.e. eGFR
of considering a time period < 36 h, there was > 60 ml.min-1.1.73 m-2)?
moderate consensus among panellists (n = 25, 57%) for There was no evidence to indicate a specific time interval
conducting hip fracture surgery within 24 h from last to general or spinal anaesthesia after the last dose of a DOAC
dose for patients who were receiving a direct thrombin for patients with a hip fracture as there have been no studies
inhibitor. specifically investigating this outcome. One retrospective
cohort study of 314 patients (47 patients taking DOACs and
Consensus statement 2: Hip fracture surgery can 267 not on anticoagulants) identified that patients taking
reasonably be performed for patients who were taking a DOACs who had neuraxial anaesthesia had a significantly
DOAC within 36 h from last dose. longer time to surgery compared with those who had general
When conducting hip fracture surgery within 36 h anaesthesia (35 h vs. 22 h; p < 0.001) [59]. In addition,
from last dose for patients taking a DOAC, each patient’s patients who were taking DOACs who had neuraxial
circumstances need to be considered. The consensus anaesthesia compared with general anaesthesia did not have
statement has considered the risks of bleeding at the a significantly longer hospital duration of stay (7.1 d vs. 6.1 d;
time of fracture and time of surgery and the overall risks p = 0.1). One retrospective cohort study of 133 patients
and benefits of expediting or delaying surgery. Practice taking DOACs found that for patients who had surgery within
is varied worldwide which has enabled results of 24 h compared with surgery > 24 h, general anaesthesia
different approaches to be published and considered, (89.2% vs. 71.6%) was more common, with fewer neuraxial
although overall the quality of evidence is low. A more (5.4% vs. 22.1%) or regional (0% vs. 17.9%) anaesthetic
conservative approach delaying surgery to allow `DOAC techniques [39].
clearance´ risks the complications of delaying surgery There were varied opinions among panellists as to how
while earlier surgery potentially could increase bleeding long the multidisciplinary team could reasonably wait
risk at the time of surgery. The consensus statement before giving general anaesthesia to patients with normal
balances these competing risks. One approach could be renal function who were taking a factor Xa inhibitor: 15
to consider if higher than expected blood loss for a panellists (34%) specified < 12 h; 13 panellists (30%)
patient could lead to an additional risk (e.g. because specified 12–24 h; and 11 panellists (25%) specified > 24–
their baseline haemoglobin level is marginal or if a 36 h. Overall, there was high consensus among panellists
patient has increased cardiovascular risk factors that may (n = 39, 89%) to reasonably consider waiting < 36 h before
lead to decreased end organ perfusion and organ giving general anaesthesia to patients receiving a factor Xa
dysfunction (e.g. cerebral ischaemia)). Elimination of a inhibitor. In terms of considering a time period < 36 h, there
DOAC is dependent on renal function, which would was moderate consensus among panellists (n = 28, 64%) to
need to be considered. Dabigatran is 80% cleared by consider waiting < 24 h before giving general anaesthesia
the kidneys, compared with 50% for edoxaban, 33% for to patients receiving a factor Xa inhibitor. There were also
rivaroxaban and 25% for apixaban. Considering the varied opinions from panellists as to how long a
elimination half-life of DOACs (i.e. 12 h for factor Xa multidisciplinary team could reasonably wait before giving

6 © 2024 Association of Anaesthetists.

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Mitchell et al. | Hip fracture management consensus for patients on DOACs Anaesthesia 2024

general anaesthesia to patients with normal renal function team could reasonably wait > 48 h before giving a spinal
receiving a direct thrombin inhibitor: panellists indicating anaesthetic. Other wait times were 24–36 h (n = 12, 27%)
wait times of < 12 h (n = 15, 34%); 12–24 h (n = 11, 25%); and > 36–48 h (n = 3, 67%). Overall, there was low
or > 24–36 h (n = 10, 23%). Overall, there was high consensus among panellists as to the amount of time a
consensus among panellists (n = 36, 82%) to reasonably multidisciplinary team could reasonably wait before giving
consider waiting < 36 h before giving general anaesthesia spinal anaesthesia to patients receiving a direct thrombin
to patients receiving a direct thrombin inhibitor. In terms of inhibitor. No consensus statement could be made
considering a time period < 36 h, there was moderate regarding how long a multidisciplinary team could
consensus among panellists (n = 26, 59%) to consider reasonably wait from last dose before giving a spinal
waiting < 24 h before giving general anaesthesia to anaesthetic to patients who were taking a DOAC (assuming
patients receiving a direct thrombin inhibitor. normal renal function i.e. eGFR > 60 ml.min-1.1.73 m-2) who
required hip fracture surgery. The potential risk of spinal
Consensus statement 3: General anaesthesia could anaesthesia, such as epidural or vertebral canal
reasonably be administered for hip fracture surgery in haematoma, versus benefit, such as patients with pulmonary
patients who were taking a DOAC < 36 hours from last or airway considerations, needs to be considered for each
dose (assuming `normal´ renal function, i.e. eGFR > 60 patient. However, this special interest group acknowledges
ml.min-1.1.73m-2). Around two-thirds of panellists also that selected patients may benefit from expedited surgery
agreed that general anaesthesia could reasonably be under spinal anaesthesia and national guidance from the
administered < 24 h after surgery (based on moderate UK advocating this after 24 h [1].
consensus).
Question 5: In patients who had a DOAC interruption
When conducting hip fracture surgery for patients for hip fracture surgery, when should a patient
taking a DOAC, each patient’s circumstances need to be recommence a DOAC (considering expected low blood
considered when deciding on mode of anaesthesia. loss and stable haemoglobin)?
Studies such as REGAIN [60], the RAGA randomised trial There was no evidence to indicate a specific time interval
[61] and ASAP-2 [62] have not shown spinal anaesthesia after surgery when patients with a hip fracture could
to be superior to general anaesthesia for hip fracture reasonably recommence taking DOACs. The Royal
surgery when considering peri-operative health Berkshire NHS Foundation Trust Perioperative Management
outcomes, such as mortality, postoperative delirium or of DOACs: Protocol [63] specifies commencing LMWH
ambulation. The positive health outcomes of expedited ≥ 6 h postoperatively and to check haemoglobin on day 1. If
hip fracture surgery, however, are well established. creatinine clearance ≥ 50 ml min-1 and there are no
Without proven benefits of spinal over general concerns over wound ooze, then the DOAC can be
anaesthesia, patients without medical comorbidities restarted 48 h postoperatively, and prophylactic LMWH
which would favour neuraxial anaesthesia, such as stopped. If creatinine clearance < 50 ml.min-1 then
pulmonary complications, could reasonably receive clinicians should liaise with the orthogeriatric team as
expedited surgery within 36 h under general anaesthesia. DOACs are contraindicated in severe chronic kidney
There were varied opinions among panellists as to how disease. If there are no concerns over wound ooze, the
long a multidisciplinary team could reasonably wait before anticoagulant of choice should then be started 48 h
giving spinal anaesthesia to patients with normal renal postoperatively and prophylactic LMWH stopped.
function taking a Xa inhibitor. Panellists indicated a wait of There were varied opinions among panellists as to when
> 48 h (n = 21, 48%), 24–36 h (n = 17, 39%) or > 36–48 h a patient could reasonably recommence a DOAC after hip
(n = 4, 9%). Overall, there was low consensus among fracture surgery. Panellists specified that a DOAC could
panellists as to the amount of time a multidisciplinary team reasonably be recommenced within > 24–36 h (n = 22,
could reasonably wait before giving spinal anaesthesia to 50%); within 48 h (n = 14, 32%); or within > 36–48 h (n = 6,
patients receiving a Xa inhibitor. 14%). Overall, there was high consensus among panellists
Varied opinions were also obtained from panellists as (n = 36, 82%) that a patient could reasonably be
to how long a multidisciplinary team could reasonably wait recommenced on a DOAC within 48 h. In terms of
before giving spinal anaesthesia to patients with normal considering a time period < 48 h, there was moderate
renal function taking a direct thrombin inhibitor, with less consensus by the panel (n = 22, 50%) to reasonably consider
than half of the panel (n = 20, 46%) agreeing that a surgical recommencing a patient on a DOAC > 24–36 h.

© 2024 Association of Anaesthetists. 7

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia 2024 Mitchell et al. | Hip fracture management consensus for patients on DOACs

Consensus statement 4: It is generally reasonable to across studies were particularly identified in the
consider recommencing a DOAC (considering blood measurement of blood loss and type of postoperative
loss and haemoglobin) within 48 h of hip fracture complications examined. Information was often absent
surgery. regarding the amount of time prior to surgery that DOAC use
The potential risk of bleeding and local wound ceased and the type of anaesthesia used during surgery. It is
complications should be individually assessed and recommended that standard definitions and approaches to
balanced against potential thromboembolic risk. the measurement of patient outcomes be developed.
Prolonged DOAC interruption could increase risk of arterial The hip fracture and DOAC working group encourage
or venous thromboembolism. For patients at highest risk, wide dissemination of this consensus statement and, as
such as those with recent stroke, deep vein thrombosis or such, have published the consensus statement as open
pulmonary embolism, recommencing DOACs within a access. The working group also encourage dissemination of
shorter time period and/or a prophylactic dose of LMWH on the consensus statement through professional networks
postoperative day 1 could be considered. and have developed a summary infographic (online
Supporting Information Appendix S7, Figure S29) outlining
Discussion the key consensus statements to aid distribution and a
These consensus statements are designed to inform decision flow chart to aid implementation into practice
multidisciplinary team care of patients with a hip fracture (online Supporting Information Appendix S7, Figure S30).
and who were taking DOACs before their injury. The There are several limitations associated with the
consensus statements should be applied in conjunction development of the consensus statements. The lack of high-
with any existing national or local facility-based hip fracture quality population-based studies on the management and
care pathways, protocols and guidelines, and considering outcomes of patients with a hip fracture taking DOACs led the
the individual circumstance of the patient, with the aim of working group to rely largely on the opinions of expert
ensuring a high quality of care for patients with a hip fracture panellists to develop the consensus statements. While
and who are taking DOACs. expert panellists were invited from all continents, we did not
The literature reviews conducted for the development obtain responses from the African region, and responses
of the consensus statements highlighted the lack of were generally obtained from panellists from high-income
definitive research evidence regarding patients taking countries. Therefore, the consensus statements may not be
DOACs and hip fracture care. Whether a delay to surgical suitable for implementation in low-resource settings.
intervention for patients with a hip fracture taking DOACs is Consensus was not achieved for how long a multidisciplinary
justified needs evidence from robust population-based team could reasonably wait from last dose before giving a
studies [1, 28]. In particular, further research is needed to spinal anaesthetic to patients who were taking a DOAC and
quantify whether time periods < 36 h from last dose could further research in this area is required to inform practice. The
be considered for peripheral nerve blocks, general or consensus statements did not specifically address patients
spinal anaesthesia, and hip fracture surgery without who experience specific comorbid conditions, such as
compromising patient outcomes. There is also a need for chronic kidney disease, which will affect decision-making
pragmatic investigation of the use of reversal agents for around hip fracture care (e.g. consideration of patients with
DOACs prior to hip fracture surgery [64] and their impact on poor renal function on admission).
patient outcomes and treatment costs. To aid population- Each consensus statement will need to be considered
based studies of health outcomes of patients with hip specific to each individual patient’s treatment. It is
fracture taking DOACs, it is recommended that hip fracture recommended that a review of the consensus statements be
registries consider recording information on DOACs and, conducted following new research that addresses the
potentially, use of any reversal agents. Research is currently knowledge gaps regarding the management to patients
being undertaken as part of the Hip and femoral fracture with a hip fracture and who are taking DOACs.
Anticoagulation Surgical Timing Evaluation (HASTE) study
in the UK [65] which may be able to provide further insight
regarding the management of patients taking DOACs. Acknowledgements
From the literature reviews, inconsistent approaches in The authors wish to thank the anonymous expert panellists
the measurement and assessment of patient health outcomes for their time in completing the modified Delphi study. FB is
were identified, leading to heterogeneity and difficulties in a recipient of a Research Early Career Award from Hamilton
comparing patient outcomes across studies. Inconsistencies Health Sciences. No other competing interests declared.

8 © 2024 Association of Anaesthetists.

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Mitchell et al. | Hip fracture management consensus for patients on DOACs Anaesthesia 2024

References 17. National Institute for Health and Care Excellence. Hip fracture:
management. [CG124]. 2011. https://www.nice.org.
1. Griffiths R, Babu S, Dixon P, et al. Guideline for the management
uk/guidance/cg124.
of hip fractures 2020: guideline by the association of
18. Australian and New Zealand Hip Fracture Registry Steering
anaesthetists. Anaesthesia 2021; 76: 225–37.
Group. Australian and New Zealand guideline for hip fracture
2. Horlocker TT, Vandermeuelen E, Kopp S, Gogarten W, Leffert L,
care: Improving outcomes in hip fracture management of
Benzon H. Regional anesthesia in the patient receiving
adults. 2014.
antithrombotic or thrombolytic therapy: American Society of
19. Roberts KC, Brox WT, Jevsevar DS, Sevarino K. Management of
regional anesthesia and pain medicine evidence-based
hip fractures in the elderly. Journal of the American Academy
guidelines (fourth edition). Regional Anesthesia and Pain
of Orthopaedic Surgeons 2015; 23: 131–7.
Medicine 2018; 43: 263–309.
20. Kirley K, Qato DM, Kornfield R, Stafford RS, Alexander GC.
3. Steffel J, Verhamme P, Potpara TS, et al. The 2018 European
National trends in oral anticoagulant use in the United States,
Heart Rhythm Association practical guide on the use of non-
2007 to 2011. Circulation: Cardiovascular Quality and
vitamin k antagonist oral anticoagulants in patients with atrial
Outcomes 2012; 5: 615–21.
fibrillation. European Heart Journal 2018; 39: 1330–93.
21. Morgan A, Joshy G, Schaffer A, Laba TL, Litchfield M,
4. Narouze S, Benzon HT, Provenzano D, et al. Interventional
Pearson S, Banks E. Rapid and substantial increases in
spine and pain procedures in patients on antiplatelet and
anticoagulant use and expenditure in Australia following
anticoagulant medications: guidelines from the American
the introduction of new types of oral anticoagulants. PLoS
Society of Regional Anesthesia and Pain Medicine, the
One 2018; 13: e0208824-e.
European Society of Regional Anaesthesia and Pain
22. Taranu R, Redclift C, Williams P, et al. Use of anticoagulants
Therapy, the American Academy of Pain Medicine, the
remains a significant threat to timely hip fracture surgery.
International Neuromodulation Society, the North
Geriatric Orthopaedic Surgery and Rehabilitation 2018; 9:
American Neuromodulation Society, and the World
2151459318764150.
Institute of Pain. Regional Anesthesia and Pain Medicine
23. Zhu J, Alexander GC, Nazarian S, Segal JB, Wu AW. Trends and
2018; 43: 225–62.
variation in oral anticoagulant choice in patients with atrial
5. Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative
fibrillation, 2010-2017. Pharmacotherapy 2018; 38: 907–20.
management of antithrombotic therapy: an American college
24. Colacci M, Tseng EK, Sacks CA, Fralick M. Oral anticoagulant
of chest physicians clinical practice guideline. Chest 2022; 162:
utilization in the United States and United Kingdom. Journal of
e207–43.
General Internal Medicine 2020; 35: 2505–7.
6. The ICM-VTE Trauma Delegates. Recommendations from the
25. Daugaard C, Pedersen AB, Kristensen NR, Johnsen SP.
ICM-VTE: Trauma. Journal of Bone and Joint Surgery 2022;
Preoperative antithrombotic therapy and risk of blood
104: 280–308.
transfusion and mortality following hip fracture surgery: a
7. Kietaibl S, Ferrandis R, Godier A, et al. Regional anaesthesia in
Danish nationwide cohort study. Osteoporosis International
patients on antithrombotic drugs: joint ESAIC/ESRA guidelines.
2019; 30: 583–91.
European Journal of Anaesthesiology 2022; 39: 100–32.
26. Lizaur-Utrilla A, Martinez-Mendez D, Collados-Maestre I,
8. Harvey N, Dennison E, Cooper C. Osteoporosis: impact on
Miralles-Mu~ noz FA, Marco-Gomez L, Lopez-Prats FA. Early
health and economics. Nature Reviews Rheumatology 2010; 6:
surgery within 2 days for hip fracture is not reliable as
99–105.
healthcare quality indicator. Injury 2016; 47: 1530–5.
9. Dyer SM, Crotty M, Fairhall N, et al. A critical review of the long-
27. Dailiana Z, Papakostidou I, Varitimidis S, Michalitsis S, Veloni A,
term disability outcomes following hip fracture. BMC Geriatrics
Malizos K. Surgical treatment of hip fractures: factors
2016; 16: 158.
influencing mortality. Hippokratia 2013; 17: 252–7.
10. Pincus D, Ravi B, Wasserstein D, et al. Association between wait
28. Papachristos IV, Giannoudis PV. Proximal femur fractures in
time and 30-day mortality in adults undergoing hip fracture
patients taking anticoagulants. EFORT Open Reviews 2020; 5:
surgery. JAMA 2017; 318: 1994–2003.
699–706.
11. Borges FK, Bhandari M, Guerra-Farfan E, et al. Accelerated
29. Shah R, Sheikh N, Mangwani J, Morgan N, Khairandish H. Direct
surgery versus standard care in hip fracture (hip attack): an
oral anticoagulants (DOACS) and neck of femur fractures:
international, randomised, controlled trial. Lancet 2020; 395:
Standardising the perioperative management and time to
698–708.
surgery. Journal of Clinical Orthopaedics and Trauma 2021; 12:
12. Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E,
138–47.
DeBeer J, Bhandari M. Effect of early surgery after hip fracture on
30. Aziz S, Almeida K, Taylor G. How should we manage hip
mortality and complications: systematic review and meta-analysis.
fracture patients on direct oral anticoagulants? BMJ Evidence-
Canadian Medical Association Journal 2010; 182: 1609–16.
Based Medicine 2021; 26: 22–3.
13. Moja L, Piatti A, Pecoraro V, et al. Timing matters in hip fracture
31. Mitchell RJ, Jakobs S, Halim N, Seymour H, Tarrant S. Synthesis
surgery: patients operated within 48 hours have better
of the evidence on the impact of pre-operative direct oral
outcomes. A meta-analysis and meta-regression of over
anticoagulants on patient health outcomes after hip fracture
190,000 patients. PLoS One 2012; 7: e46175-e.
surgery: rapid systematic review. European Journal of Trauma
14. Leer-Salvesen S, Engesæter LB, Dybvik E, Furnes O, Kristensen
and Emergency Surgery 2022; 48: 2567–87.
TB, Gjertsen J-E. Does time from fracture to surgery affect
32. You D, Xu Y, Ponich B, et al. Effect of oral anticoagulant use
mortality and intraoperative medical complications for hip
on surgical delay and mortality in hip fracture: a systematic
fracture patients? An observational study of 73 557 patients
review and meta-analysis. Bone and Joint Journal 2021;
reported to the Norwegian hip fracture register. Bone and Joint
103: 222–33.
Journal 2019; 101-B: 1129–37.
33. White SM, Altermatt F, Barry J, et al. International fragility
15. Klestil T, R€
oder C, Stotter C, et al. Impact of timing of surgery in
fracture network Delphi consensus statement on the principles
elderly hip fracture patients: a systematic review and meta-
of anaesthesia for patients with hip fracture. Anaesthesia 2018;
analysis. Scientific Reports 2018; 8: 13933.
73: 863–74.
16. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing
34. WikiGuidelines. Wikiguidelines charter. 2022. https://www.
of surgery for hip fracture and patient outcomes. JAMA 2004;
wikiguidelines.com/charter.
291: 1738–43.

© 2024 Association of Anaesthetists. 9

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia 2024 Mitchell et al. | Hip fracture management consensus for patients on DOACs

35. Kidney Disease Improving Global Outcomes. Consensus 51. Schermann H, Gurel R, Gold A, Maman E, Dolkart O, Steinberg
Conference on Nomenclature for kidney Function and EL, Chechik O. Safety of urgent hip fracture surgery protocol
Disease. Amsterdam. 2019. https://kdigo.org/conferences/ under influence of direct oral anticoagulation medications.
nomenclature. Injury 2019; 50: 398–402.
36. Sharkey SB, Sharples AY. An approach to consensus building 52. Shani M, Yahalom R, Comaneshter D, Holtzman K,
using the Delphi technique: developing a learning resource in Blickstein D, Cohen A, Lustman A. Should patients treated
mental health. Nurse Education Today 2001; 21: 398–408. with oral anti-coagulants be operated on within 48 h of
37. Dayan RR, Ayzenberg Y, Slutsky T, Shaer E, Kaplan A, Zeldetz V. hip fracture? Journal of Thrombosis and Thrombolysis
Safety of femoral nerve blockage for hip fractures in adult 2021; 51: 1132–7.
patients treated with anti-xa direct oral anticoagulants: a pilot 53. Goh EL, Chidambaram S, Rai S, Kannan A, Anand S. Timing of
study. Israel Medical Association Journal 2021; 23: 590–4. surgery for hip fracture in patients on direct oral anti-
38. Guay J, Kopp S. Peripheral nerve blocks for hip fractures in coagulants: a population-based cohort study. Geriatric
adults. Cochrane Database of Systematic Reviews 2020; 11: Orthopaedic Surgery and Rehabilitation 2022; 13. https://doi.
CD001159. org/10.1177/2151459 3221088405.
39. Levack AE, Moore HG, Stephan S, et al. Delayed surgery does 54. Franklin NA, Ali AH, Hurley RK, Mir HR, Beltran MJ. Outcomes of
not reduce transfusion rates in low-energy hip fractures on early surgical intervention in geriatric proximal femur fractures
direct oral anticoagulants. Journal of Orthopaedic Trauma among patients receiving direct oral anticoagulation. Journal of
2022; 36: 172–8. Orthopaedic Trauma 2018; 32: 269–73.
40. Aigner R, Buecking B, Hack J, et al. Effect of direct oral 55. Mullins B, Akehurst H, Slattery D, Chesser T. Should surgery be
anticoagulants on treatment of geriatric hip fracture patients: delayed in patients taking direct oral anticoagulants who suffer
an analysis of 15,099 patients of the AltersTraumaRegister a hip fracture? A retrospective, case-controlled observational
DGUâ. Medicina (Kaunas, Lithuania) 2022; 58: 379. study at a UK major trauma centre. BMJ Open 2018; 8:
41. Brown A, Zmich Z, Roberts A, Lipof J, Judd KT. Expedited e020625.
surgery in geriatric hip fracture patients taking direct oral 56. Tarrant SM, Catanach MJ, Sarrami M, Clapham M, Attia J,
anticoagulants is not associated with increased short-term Balogh ZJ. Direct oral anticoagulants and timing of hip fracture
complications or mortality rates. OTA International 2020; 3: surgery. Journal of Clinical Medicine 2020; 9: 2200.
e089. 57. Tran T, Delluc A, de Wit C, Petrcich W, Le Gal G, Carrier M. The
42. Cafaro T, Simard C, Tagalakis V, Koolian M. Delayed time to impact of oral anticoagulation on time to surgery in patients
emergency hip surgery in patients taking oral anticoagulants. hospitalized with hip fracture. Thrombosis Research 2015; 136:
Thrombosis Research 2019; 184: 110–4. 962–5.
43. Frenkel Rutenberg T, Velkes S, Vitenberg M, et al. Morbidity 58. Bruckbauer M, Prexl O, Voelckel W, Ziegler B, Grottke O,
and mortality after fragility hip fracture surgery in patients Maegele M, Sch€ ochl H. Impact of direct oral anticoagulants in
receiving vitamin k antagonists and direct oral anticoagulants. patients with hip fractures. Journal of Orthopaedic Trauma
Thrombosis Research 2018; 166: 106–12. 2019; 33: E8–E13.
44. Gill SK, Theodorides A, Smith N, Maguire E, Whitehouse SL, 59. Leer-Salvesen S, Dybvik E, Ranhoff AH, Husebø BL, Dahl OE,
Rigby MC, Ivory JP. Wound problems following hip Engesæter LB, Gjertsen JE. Do direct oral anticoagulants
arthroplasty before and after the introduction of a direct (doacs) cause delayed surgery, longer length of hospital stay,
thrombin inhibitor for thromboprophylaxis. Hip International and poorer outcome for hip fracture patients? European
2011; 21: 678–83. Geriatric Medicine 2020; 11: 563–9.
45. Hourston GJM, Barrett MP, Khan WS, Vindlacheruvu M, 60. Neuman MD, Ellenberg SS, Sieber FE, Magaziner JS, Feng R,
McDonnell SM. New drug, new problem: do hip fracture Carson JL. Regional versus general anesthesia for promoting
patients taking NOACS experience delayed surgery, longer independence after hip fracture (REGAIN): protocol for a
hospital stay, or poorer outcomes? Hip International 2020; 30: pragmatic, international multicentre trial. BMJ Open 2016; 6:
799–804. e013473.
46. King K, Polischuk M, Lynch G, et al. Early surgical fixation for hip 61. Li T, Li J, Yuan L, et al. Effect of regional vs general anesthesia on
fractures in patients taking direct oral anticoagulation: a incidence of postoperative delirium in older patients
retrospective cohort study. Geriatric Orthopaedic Surgery undergoing hip fracture surgery: the RAGA randomized trial.
and Rehabilitation 2020; 11: 2151459320944854. JAMA 2022; 327: 50–8.
47. Krespi R, Ashkenazi I, Shaked O, Kleczewski J, Ben-Tov T, 62. White SM, Moppett I, Griffiths R, et al. Secondary analysis of
Steinberg E, Khoury A. Early versus delayed surgery for hip outcomes after 11,085 hip fracture operations from the
fragility fractures in patients treated with direct oral prospective UK anaesthesia sprint audit of practice (ASAP-2).
anticoagulants. Archives of Orthopaedic and Trauma Surgery Anaesthesia 2016; 71: 506–14.
2022; 142: 3279–84. 63. Anazor F, Kulkarni A, Barnard K, Lancaster S, Pollard T. Timing
48. Lott A, Haglin J, Belayneh R, Konda SR, Leucht P, Egol KA. and safety of hip fracture surgery in patients on direct-acting
Surgical delay is not warranted for patients with hip fractures oral anticoagulants. Journal of Clinical Orthopaedics and
receiving non-warfarin anticoagulants. Orthopedics 2019; 42: Trauma 2023; 36: 102080.
E331–5. 64. Chaudhary R, Sharma T, Garg J, et al. Direct oral
49. Mahmood A, Thornton L, Whittam DG, Maskell P, Hawkes DH, anticoagulants: a review on the current role and scope of
Harrison WJ. Pre-injury use of antiplatelet and anticoagulations reversal agents. Journal of Thrombosis and Thrombolysis 2020;
therapy are associated with increased mortality in a cohort of 49: 271–86.
1038 hip fracture patients. Injury 2021; 52: 1473–9. 65. Alanie M, Eardley W, Baxter M, Kottam L. A multicentre
50. Mayor A, Brooke B, Stephenson J. Reducing delays to surgery prospective service evaluation of timing of surgery in older hip
and achieving best practice tariff for hip fracture patients on and femoral fracture patients on oral anticoagulants: South
direct oral anticoagulants (DOACS): a protocol for expediting Tees: James Cook University Hospital, 2023. https://www.
surgery without increasing peri-operative complications. southtees.nhs.uk/about/strive/research-team/aces/world-leadi
Trauma 2023. Epub 6 April. https://doi.org/10.1177/146040 ng/present/haste-study-hip-and-femoral-fracture-anticoagulati
86231165567. on-surgical-timing-evaluation.

10 © 2024 Association of Anaesthetists.

 13652044, 0, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16226 by <Shibboleth>[email protected], Wiley Online Library on [25/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Mitchell et al. | Hip fracture management consensus for patients on DOACs Anaesthesia 2024

Supporting Information Appendix S4. 11th Global FFN Congress 2023:

Additional supporting information may be found online via Finalising a consensus statement on the principles for
the journal website. management of hip fracture patients taking direct oral
anticoagulants.
Appendix S1. 10th Global FFN Congress 2022: Appendix S5. Consensus statements for the
Management of hip fracture patients taking DOACs management of hip fracture patients taking DOACs.
workshop. Appendix S6. Summary of guideline
Appendix S2. Modified-Delphi round 1 survey. recommendations.
Appendix S3. Modified-Delphi round 2. Appendix S7. Dissemination and implementation.

© 2024 Association of Anaesthetists. 11