A SURVEY OF CURRENT PRACTICE AMONGST ORTHOPAEDIC DEPARTMENTS IN THE UK REGARDING THE ROUTINE DISCONTINUATION OF CLOPIDOGREL PRIOR TO UNDERTAKING EMERGENCY SURGERY FOR FEMORAL NECK FRACTURES

Abstract

Introduction: Approximately 60000 patients are admitted each year in the UK with neck of femur fractures, the vast majority of whom are elderly presenting with multiple medical comorbidities, including a history of ischaemic heart disease and stroke. They are often on a number of regular medications which may include aspirin, warfarin and more recently, clopidogrel. Clopidogrel and aspirin are associated with an increased bleeding time especially if present as a combined therapy. As such, they can lead to bleeding complications in patients undergoing surgery, increasing the need to transfuse such patients and increasing the risk of cardiovascular events as a result of anaemia. Although clopidogrel is often stopped for patients undergoing elective surgery for a period of 7–10 days, to our knowledge, no such guidelines are available regarding the discontinuation of clopidogrel in patients undergoing surgery for femoral neck fractures. The aim of conducting this survey was to investigate the current practice of various orthopaedic units in the UK with regards to stopping clopidogrel in such patients.

Methods: A telephone questionnaire survey was conducted on junior doctors (House officers, Senior House Officers and Registrars) in orthopaedic departments in the UK which routinely admit and treat patients with fractured neck of femurs.

1. Does your trust/department have a policy on discontinuing clopidogrel in patients who are due to have emergency trauma surgery such as operative fixation for femoral neck fractures?

2. If yes: how many days prior to surgery is the clopidogrel discontinued?

3. If no: are any precautions undertaken?

   1. Clotting function checked:

   2. Platelet cover/other blood products:

   3. Increased X matching of packed red cells:

   4. Other precautions?

4. Any complications as a result of clopidogrel?

Results: 184 NHS trusts in the UK were involved. 45% of trusts stop clopidogrel routinely prior to performing surgery on patients with femoral neck fractures. The number of days clopidogrel is stopped prior to surgery varied from 1 – 7 days. 55% of trusts did not routinely stop aspirin prior to surgery. 97% of trusts routinely stopped warfarin prior to surgery and the target INR varied from < 1.0 – < 3.2.

Conclusions: It is clear from this study that a wide range of policies exists amongst orthopaedic departments in the UK regarding the routine discontinuation of clopidogrel, aspirin and warfarin in patients with femoral neck surgery who are awaiting surgery. This highlights the need for further debate and guidelines regarding the routine discontinuation of clopidogrel.