Anticoagulation before urgent surgery — MCCQE Part 1 MCQ

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HardPre-operative AssessmentAnticoagulation before urgent surgeryMCCQE Part 1

An 82-year-old with a displaced hip fracture takes apixaban for atrial fibrillation. The last dose was eight hours ago and Cockcroft–Gault creatinine clearance is 35 mL/min. She is stable, without active bleeding, and needs urgent fixation. What is the best immediate plan?

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Correct answer: D — Withhold apixaban and activate a coordinated urgent-surgery plan

Apixaban should be withheld and orthopedics, anesthesia, and thrombosis or hematology should coordinate an urgent plan using the last dose, kidney function, operative and neuraxial bleeding risk, and the harm of delaying hip-fracture repair. A fixed elective interruption table cannot be applied blindly to an urgent fracture, and local access to calibrated anti-Xa testing or reversal may affect exceptional cases. Vitamin K reverses warfarin, not apixaban. Routine therapeutic heparin bridging is unnecessary because DOACs have rapid offset and onset and bridging increases bleeding. Proceeding eight hours after a dose without anesthetic review may be unsafe, especially if neuraxial anesthesia is contemplated. Conversely, a universal two-week delay exposes the patient to immobility, delirium, and other complications. Postoperative prophylaxis and resumption are individualized after hemostasis.

Reference: Thrombosis Canada, DOACs: Perioperative Management: https://thrombosiscanada.ca/hcp/practice/clinical_guides?guideID=PERIOPERATIVEMANAGEMENTOFPATIE&language=en-ca