DELAY IN THEATRE TIME IN PATIENTS WITH PROXIMAL FEMUR FRACTURES ON WARFARIN

Abstract

Introduction: We found some unusually long delays and repeated canellations in patients on warfarin and associated proximal femur fractures. Aim of our study was to find the safe INR levels at which the patients can be subjected to surgery and if possible determine the approximate time when patients would reach the safe levels based on INR results at admission. Generally an INR level of less than 2.0 is considered safe and there is no set policy within hospitals on advance booking of these patients.

Methods: We identified all proximal femur fractures in a one year period in our hospital who were on warfarin, determined the reason for which they were on warfarin. Checked INR, LFTS and Renal function on admission. Patients had daily INR levels done at 6’oclock in morning to determine the suitability for theatre.

Results: There were 23 patients of total 437 patients with proximal femur fractures on warfarin. Single most important reason for treatment on warfarin was atrial fibrillation(in 18 patients),other reasons were thromboembolic disease, recurrent pulmonary embolism and heart valve replacement. The INR on admission ranged 1.6–4.0 with a mean of 2.6.We found that most patients with an INR less than 3.0 on admission had acceptable levels within three days of admission whilst those with an INR greater than 3.1 had an acceptable levels within four days. In patients with raised LFTS or renal function impairment took longer time to settle.

Conclusion: We recommend that patients with an INR less than 3.0 can be provisionally booked for theatre 3 days from admission while those with an INR 3.1–4.0 can be listed for theatre 4 days from admission except where there is a grossly altered renal or liver function. By listing patients in above method, unexpected cancellations and the practice of keeping the patients fasted on a daily basis can be avoided.