skip to main content

Anticoagulation and Neuraxial Block — FRCA Final MCQ

Instant feedback + full explanation. One question, done properly.

HardRegional AnaesthesiaAnticoagulation and Neuraxial BlockFRCA Final

A 77-year-old woman with a fractured neck of femur is listed for urgent hemiarthroplasty. She takes apixaban 5 mg twice daily for atrial fibrillation; her last dose was 14 hours ago. Her eGFR is 82 mL/min/1.73 m2, she has no active bleeding, and an operating theatre is available now. Further delay would prevent surgery on the day of or the day after admission, as recommended by NICE CG124. What is the most appropriate management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Withhold apixaban and proceed now under general anaesthesia without routine anticoagulant reversal

The best answer is B. Current Association of Anaesthetists-led consensus supports hip-fracture surgery and general anaesthesia within 36 hours of the last DOAC dose when eGFR is above 60 mL/min/1.73 m2. At only 14 hours, residual apixaban makes neuraxial puncture inappropriate, but delaying urgent surgery solely to permit spinal anaesthesia is not supported; consensus has not established a safe early interval for spinal anaesthesia. Idarucizumab reverses dabigatran, not apixaban. Andexanet alfa is licensed for life-threatening or uncontrolled bleeding and its SmPC states that it is unsuitable for pretreatment before urgent surgery. PCC lacks established clinical evidence for routine apixaban reversal and neither PCC nor andexanet should be used merely to facilitate spinal anaesthesia in a non-bleeding patient.

Reference: Association of Anaesthetists, Principles for management of hip fracture for older adults taking direct oral anticoagulants: an international consensus statement, 2024. https://pubmed.ncbi.nlm.nih.gov/38319797/