Elderly hip fracture in a patient taking warfarin
An 82-year-old woman who lives independently falls at home and sustains a displaced left femoral neck fracture. She takes warfarin for permanent atrial fibrillation, bisoprolol, ramipril and atorvastatin. Her INR today is 3.2; her eGFR is 38 mL/min/1.73 m². She has no chest pain, no bleeding and is haemodynamically stable. Haemoglobin is 10.8 g/dL and platelets 210 × 10⁹/L. The orthopaedic team wants to operate in 6 hours because of pressure on theatre time. The anaesthetist is concerned about the INR and asks you to review. The hospital has prothrombin complex concentrate (PCC) available but no idarucizumab or andexanet. There is no on-site haematology laboratory after 8 pm. She is alert and has capacity. Her daughter asks whether the operation can wait until the warfarin 'wears off'.
1. What is your immediate anticoagulation plan before surgery? Specify agents, doses and target INR, and explain the competing risks.
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Priority: reverse anticoagulation while avoiding unnecessary delay.
- Give vitamin K 5 mg IV slowly plus PCC 25–35 IU/kg (based on INR 3.2) to target INR <1.5. Recheck INR 30 minutes after PCC; if still >1.5, give a further small dose.
- Do not use FFP as first-line: it is less effective, takes longer to thaw and risks fluid overload in an 82-year-old.
- The competing risks: untreated INR >1.5 increases intra- and postoperative bleeding, but delay beyond 48 hours increases mortality, delirium, pressure injury and VTE. A short reversal is therefore justified.
- Her AF thrombotic risk is high, but the reversal window is brief; avoid over-correction to a supranormal haemostatic state.
- Because the on-site laboratory closes at 8 pm, arrange point-of-care INR or a validated transfer protocol; do not give PCC without a repeat INR plan.
Dose rationale: PCC replaces factors II, VII, IX and X immediately; vitamin K ensures sustained reversal as PCC wears off.
2. How would you advise the orthopaedic team on timing of surgery, and what anaesthetic or logistical factors influence your recommendation?
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- Do not wait for warfarin to 'wear off'; that would take days and is unacceptable.
- Aim for surgery within 36 hours of admission, once INR <1.5 and the patient is optimised. If INR remains >1.5 at 6 hours, delay until corrected rather than operate on a coagulopathic patient.
- Anaesthetic factors: spinal anaesthesia is generally avoided until coagulation is normal; general anaesthesia is acceptable but carries delirium risk. Discuss with a senior anaesthetist.
- Logistical factors: theatre availability, blood bank, and after-hours laboratory support. If reversal cannot be monitored safely overnight, operate the next morning with a documented plan.
- Explain to the daughter that early surgery is safer than waiting, and that the reversal agents are given specifically to make surgery safe.
3. Outline the postoperative plan for thromboprophylaxis and restarting anticoagulation.
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- Mechanical prophylaxis (intermittent pneumatic compression and graduated stockings) from admission unless contraindicated.
- Start prophylactic LMWH (e.g. enoxaparin 40 mg SC daily) 24 hours after surgery once haemostasis is secure; her eGFR of 38 does not require dose reduction for prophylaxis but monitor renal function.
- Restart warfarin at her usual maintenance dose when she is eating and there is no active bleeding, usually on day 1–2. Bridge with LMWH until INR is ≥2.0 on two consecutive days.
- Continue thromboprophylaxis for 28–35 days after hip fracture surgery, per guideline.
- Monitor INR daily initially; avoid NSAIDs and interacting drugs; ensure follow-up.