Displaced femoral neck fracture in an older woman taking apixaban
An 82-year-old woman is brought in at 22:00 after falling at home. She has a displaced intracapsular fracture of the left femoral neck. She lives alone, mobilises with a stick, and is independent in activities of daily living. Her medications are apixaban 5 mg twice daily for atrial fibrillation, bisoprolol 2.5 mg, atorvastatin 20 mg and amlodipine 5 mg. Her last apixaban dose was at 08:00, 14 hours ago. Examination: pulse 76 and irregular, blood pressure 148/82, GCS 15, no head injury, no other injuries. Bloods: haemoglobin 108 g/L, platelets 232 × 10⁹/L, creatinine 118 µmol/L, eGFR 46 mL/min/1.73 m², INR 1.2, ALT normal. The on-call anaesthetist asks whether the operation should be done tonight, tomorrow morning, or after a 48-hour delay, and whether the anticoagulant should be reversed.
1. How would you weigh the timing of surgery against the bleeding risk, and what would you advise the anaesthetist?
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Two competing harms need to be balanced. Delaying surgery beyond 48 hours in hip fracture increases mortality, pneumonia, pressure ulcers, delirium and length of stay, and most guidelines aim for surgery within 36–48 hours. Operating on a patient with circulating apixaban risks major bleeding, and with a neuraxial block, spinal haematoma.
Key pharmacokinetics: apixaban has a half-life of about 12 hours normally, prolonged to roughly 15–17 hours at an eGFR of 46, and the last dose was 14 hours ago - so approximately one half-life has elapsed and meaningful anticoagulant effect remains. Operating tonight would be too soon. A reasonable plan is to delay to the next morning, by which time about 24 hours will have passed since the last dose, or to the following morning (roughly 36–48 hours) if anti-Xa testing is unavailable and bleeding risk is judged high. The delay should be used for optimisation, not idleness: analgesia including a fascia iliaca or femoral nerve block (safe with anticoagulation if guidelines are followed), hydration, pressure-area care, delirium screening and VTE prophylaxis planning.
Routine reversal in a non-bleeding patient is not recommended - prothrombin complex concentrate or andexanet is reserved for life-threatening bleeding or urgent surgery that cannot wait. INR is uninformative for apixaban. If available, a calibrated anti-Xa level helps; a level below about 30 ng/mL suggests surgery can proceed.
2. What intraoperative and anaesthetic considerations would you raise, and what would you do about thromboprophylaxis and restarting anticoagulation?
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Anaesthesia: general or spinal are both acceptable once an adequate interval has elapsed; if a neuraxial technique is chosen, adhere to the recommended interval after the last apixaban dose (typically at least 48 hours in renal impairment, otherwise around 36 hours) and avoid neuraxial if the interval is shorter. If surgery is brought forward, general anaesthesia avoids the spinal haematoma risk. Aim for a short procedure, maintenance of normothermia, blood pressure targets appropriate for her age, and blood conservation - she is already anaemic at 108 g/L, so group and save, and consider tranexamic acid and cell salvage per local policy.
Prophylaxis: mechanical prophylaxis (intermittent calf compression) from admission, with pharmacological prophylaxis timed after surgery once haemostasis is secured, usually 24–48 hours postoperatively for a DOAC, guided by the surgeon and anaesthetist.
Restarting apixaban: her stroke risk is high (age 82 plus likely hypertension and other factors, so CHA₂DS₂-VASc well above the threshold), and stopping it indefinitely is not acceptable. Restart at about 24–72 hours postoperatively depending on haemostasis, wound status and drain output, with the decision documented. No heparin bridging is needed for a DOAC. Review the apixaban dose - age over 80 alone does not mandate a lower dose, but weight and renal function should be checked against the licensed criteria.
3. The patient becomes confused and hypotensive 6 hours after admission, before any surgery. How does this change your plan?
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New hypotension and confusion in an elderly patient with a hip fracture and recent anticoagulation demands that bleeding be excluded first. Check for a concealed site: repeat full blood count and coagulation, and consider a CT head - a fall in someone on apixaban can cause an intracranial bleed even without a witnessed head strike, and the history may be unreliable. Also look for a hip-site haematoma, retroperitoneal bleeding, and other causes of hypotension: sepsis (urine, chest, pressure areas), dehydration, myocardial infarction with atrial fibrillation, pulmonary embolism, and drug effects including bisoprolol and amlodipine.
If intracranial or other major bleeding is confirmed, this becomes an emergency: reverse anticoagulation with prothrombin complex concentrate or, where available and appropriate, andexanet alfa, alongside neurosurgical or orthopaedic review. If no bleeding is found and the cause is septic or hypovolaemic, resuscitate and treat the cause; surgery may still proceed once stable.
Delirium is common in this group and is not a reason to defer surgery indefinitely - untreated pain and a long delay worsen it. Document the assessment, involve orthogeriatric and anaesthetic teams, and revisit the timing decision. If surgery is delayed, ensure ongoing analgesia, pressure relief and thromboprophylaxis are not forgotten, and discuss ceilings of treatment with the family if her condition deteriorates.