An 81-year-old woman is seen for a preoperative assessment prior to hip surgery. The patient presented yesterday evening after tripping while walking and falling from a standing height. She had no head trauma or loss of consciousness, but she injured her left hip. Evaluation revealed a left femoral neck fracture, and surgical repair is planned. Her other medical problems include hypertension, paroxysmal atrial fibrillation, and mild dementia. The patient takes donepezil, dabigatran, and metoprolol. She did not receive dabigatran last night or this morning in the hospital. The patient cannot recall if she took her medications yesterday morning or the day before, and her daughter was unable to determine this from the number of pills remaining in her mother's medication bottles.
Vital signs are within normal limits. Physical examination is notable for bruising and tenderness of the left hip.
Blood cell counts and serum chemistry studies are within normal limits. Other laboratory findings are as follows:
Which of the following is the most appropriate recommendation regarding surgery and anticoagulation use in this patient?

Question

An 81-year-old woman is seen for a preoperative assessment prior to hip surgery.  The patient presented yesterday evening after tripping while walking and falling from a standing height.  She had no head trauma or loss of consciousness, but she injured her left hip.  Evaluation revealed a left femoral neck fracture, and surgical repair is planned.  Her other medical problems include hypertension, paroxysmal atrial fibrillation, and mild dementia.  The patient takes donepezil, dabigatran, and metoprolol.  She did not receive dabigatran last night or this morning in the hospital.  The patient cannot recall if she took her medications yesterday morning or the day before, and her daughter was unable to determine this from the number of pills remaining in her mother's medication bottles.
Vital signs are within normal limits.  Physical examination is notable for bruising and tenderness of the left hip.
Blood cell counts and serum chemistry studies are within normal limits.  Other laboratory findings are as follows:
 Which of the following is the most appropriate recommendation regarding surgery and anticoagulation use in this patient?

Quizplus · Accepted Answer

The ongoing physiologic effects of dabigatran, a direct thrombin inhibitor used as an oral anticoagulant, can be assessed using thrombin time: Normal thrombin time: The patient is not anticoagulated - surgery can proceed without additional interventions.Elevated thrombin time: The patient is currently anticoagulated - administration of the dabigatran antidote idarucizumab should be considered in patients with life-threatening bleeding and those who require urgent/emergency surgery (Choice B). Normal thrombin time: The patient is not anticoagulated - surgery can proceed without additional interventions. Normal thrombin time: The patient is not anticoagulated - surgery can proceed without additional interventions. Elevated thrombin time: The patient is currently anticoagulated - administration of the dabigatran antidote idarucizumab should be considered in patients with life-threatening bleeding and those who require urgent/emergency surgery (Choice B). Elevated thrombin time: The patient is currently anticoagulated - administration of the dabigatran antidote idarucizumab should be considered in patients with life-threatening bleeding and those who require urgent/emergency surgery (Choice B). Patients on dabigatran undergoing elective procedures are generally advised to discontinue the medication 48 hours prior to the operation (as the half-life is approximately 12 hours). These individuals usually do not require a thrombin time. (Choice A) Prothrombin complex concentrate contains vitamin K-dependent clotting factors and is used to reverse the anticoagulant effects of warfarin. It would not effectively reverse a direct thrombin inhibitor. (Choice C) This patient has a normal thrombin time indicating that she is no longer anticoagulated. There is no need to delay surgery. (Choice D) Plasma anti-factor Xa activity levels can be used to determine whether factor Xa inhibitors such as rivaroxaban and apixaban are physiologically active. Because dabigatran is a direct thrombin inhibitor, not a factor Xa inhibitor, this test would not provide clinically useful information. Educational objective: Dabigatran is a direct thrombin inhibitor used for anticoagulation. Patients on this medication who require urgent or emergency procedures should undergo thrombin time testing. Those with normal thrombin times are not anticoagulated and can proceed with surgery. If thrombin time is elevated, administration of the dabigatran antidote idarucizumab should be considered. __________

An 81-Year-Old Woman Is Seen for a Preoperative Assessment Prior