Should surgical repair of hip fracture be delayed in patients who are receiving the anti-platelet drug Plavix?

A colleague in North Dakota reports that the orthopedists at her facility are questioning how long it is appropriate to delay surgery for patients who have suffered a hip fracture, if the patient is taking the anti-platelet drug Plavix at the time of the injury. Apparently the anesthesiologists at the facility are delaying these cases from going to surgery over concerns of Plavix-induced excessive bleeding. However, the orthopedists are rightly concerned about an increased risk of mortality in these patients, while they are awaiting surgical repair of the fracture. The inquiring colleague hopes that others might share their experience with dealing with this group of patients.

The following responses have been received.

1. Editor's note: The discussions at the following links may be germane to this discussion:
   • How long should you wait after administering a dose of the platelet inhibitor Plavix (clopidogrel) before a patient may be transfused with platelets?
   • Does platelet transfusion help patients who bleed while on the drug Reopro?
   • Platelet transfusions during cardiothoracic surgery

ADDENDA Jan. 25, 2004

2. In the opinion of Jean-François Hardy MD, Professor and Chairman of the Department of Anesthesiology at the University of Montreal (attribution used with permission) the issue of when to stop antiplatelet drugs in patients coming for emergency hip surgery is a difficult one and should not be dealt with lightly. According to Dr. Hardy, "On one hand, it is well known that these patients should be operated as soon as possible in order to improve outcome. On the other, proceeding immediately with surgery in these patients will be associated with a risk of increased bleeding and transfusion. Delaying surgery in order to stop antiplatelet drugs will not only increase orthopedic morbidity but, in addition, risk the recurrence of the condition for which the antiplatelet agent (clopidogrel) was administered. It has been shown that interruption of therapy with antiplatelet agents is accompanied by catastrophic morbidity in patients with recent coronary stenting. Thus, the clinician must balance competing risks. Few studies have addressed these issues. Experts would tend to favor an approach whereby therapy with antiplatelet drugs is interrupted as briefly as possible and resumed rapidly after the operation. As mentioned previously in this forum, platelet activity of the order of 50% is likely to be sufficient for surgery. Waiting for 5 days would, in theory, be enough to secure effective hemostasis while minimizing the period of time during which patients are left "unprotected". Should one have to proceed more rapidly, given the variability of the response to antiplatelet agents, I would proceed (avoiding regional anesthesia), observe bleeding and transfuse platelets as necessary, not prophylactically. In my view, the prophylactic transfusion of platelets should be avoided in these patients to avoid reactivating their underlying thrombotic condition."
   
   Dr. Hardy has provided two references that e-Network Forum colleagues might consider reading:
   • Rounds from the Department of Anesthesiology, University of Montreal Faculty of Medicine, May 2002. Antiplatelet agents and perioperative bleeding [PDF file] (Dr. Hardy also points out that Anesthesiology Rounds are available free of charge here.)
   • T. Kövesi and D. Royston. Editorial I: Is there a bleeding problem with platelet-active drugs? Br. J. Anaesth. 2002 88: 159-163. (NOTE: This item requires a subscription to the British Journal of Anaesthesia Online; or a pay-per-article, good for 24 hours.)
   Dr. Hardy also commented that he found the information posted in the June 2001 e-Network Forum discussion, How long should you wait after administering a dose of the platelet inhibitor Plavix (clopidogrel) before a patient may be transfused with platelets? to be most useful.

ADDENDA Sept. 19, 2005

3. The Director of a hospital-based "Blood Conservation Program" in New Jersey is interested to learn how others handle bleeding in patients who have 'Plavix-on-board', but who refuse blood transfusion therapy for religious reasons. She is aware of at least one Jehovah's Witness patient who after getting Plavix suffered a hip fracture, but refused medically justifiable blood transfusion. The patient's bleeding stopped upon administration of rFVIIa. She wonders if others would share their experiences (good or bad) with controlling bleeding in patients who have Plavix on board, but who refuse transfusions to treat their bleeding.

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Ira A. Shulman, MD
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