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
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)
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