Managing Cold Aglutinin in Surgical Patients

Q: 54 year old male with known coronary artery disease (CAD) is admitted to ICU with severe ischemic cardiogenic shock. After hemodynamic stabilization, bypass surgery is recommended by cardiology service. Patient has a documented history of Cold Agglutinin Disease. All of the following precautions or interventions may help except?

A) Plasmapheresis just prior to surgery with avoidance to any exposure to cold solution 
B) Forced warm air on the operative field 
C) Intravenous solutions and blood products to be warmed up appropriately before infusion 
D) Post-op room temperature at adequate levels
E) Emergent splenectomy if patient crash during surgery due to cold agglutination



Answer:  E

Patients with cold agglutinin impose specific challenges when it comes to surgery due to exposure of cold at various steps of surgery. The whole staff need to be aware of exposure to cold in such patients prior to surgery. Beside precautions (choices B, C , and D).

Plasmapheresis (Choice A) just prior to surgery with avoidance to any exposure to cold solution may be an option in very fragile patients. Effect of plasmapheresis lasts for five days to get through the immediate operative and post-operative period. 

Interestingly, spleen is not the organ of red cell destruction in cold agglutinin disease.  It is liver. So splenectomy may not be of much help. It is helpful in rare subgroup of patients who have cold agglutinin disease in with autoantibody IgG. (Choice E) 

#surgicalcriticalcare
#hematology


References: 

1. Berentsen S, Ulvestad E, Langholm R, et al. Primary chronic cold agglutinin disease: a population based clinical study of 86 patients. Haematologica 2006; 91:460. 

2.  Bedrosian CL, Simel DL. Cold hemagglutinin disease in the operating room. South Med J 1987; 80:466. 

3. Beebe DS, Bergen L, Palahniuk RJ. Anesthetic management of a patient with severe cold agglutinin hemolytic anemia utilizing forced air warming. Anesth Analg 1993; 76:1144. 

4. Talisman R, Lin JT, Soroff HS, Galanakis D. Gangrene of the back, buttocks, fingers, and toes caused by transient cold agglutinemia induced by a cooling blanket in a patient with sepsis. Surgery 1998; 123:592. 

5. Barbara DW, Mauermann WJ, Neal JR, et al. Cold agglutinins in patients undergoing cardiac surgery requiring cardiopulmonary bypass. J Thorac Cardiovasc Surg 2013; 146:668.

6. Zoppi M, Oppliger R, Althaus U, Nydegger U. Reduction of plasma cold agglutinin titers by means of plasmapheresis to prepare a patient for coronary bypass surgery. Infusionsther Transfusionsmed 1993; 20:19.