What is cold agglutinin disease managed in surgical patients?

Updated: Aug 28, 2018
  • Author: Salman Abdullah Aljubran, MD; Chief Editor: Michael A Kaliner, MD  more...
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Answer

Critical planning is needed if a patient with a high titer, high thermal amplitude cold agglutinin requires cooling for cardiovascular surgery. Antibody activation may lead to hemolysis, renal failure, hepatic failure, and myocardial or cerebral infarctions.

The temperature below which antibody activation occurs should be quantified preoperatively. These patients may require monitoring of core body temperatures to avoid cooling to temperatures at which the cold agglutinin is still active. Reducing the titer of the cold agglutinin to lower its effective thermal amplitude may be needed during preoperative preparation of the patient.

Ambient operating room temperatures usually result in cooling of the patient and require close attention.

In patients requiring bypass surgery, a high titer of cold agglutinin is reduced by a combination of plasmapheresis and hemodilution achieved by standard techniques used in open-heart surgery. The laboratory can help to assess the temperature range of cold agglutinin activity after the titer has been reduced so that a minimum target temperature may be estimated. Surgical techniques employing normothermic cardiopulmonary bypass and continuous warm blood cardioplegia have been successful. [60, 61]

In one study at the Mayo Clinic of 16 patients undergoing cardiopulmonary bypass procedures, 6 patients were found to have cold hemagglutinin disease. In 3 of the patients, cold agglutinin detection was made intraoperatively. The lowest recorded intraoperative core temperature, in 1 case, was under 34° C. None of the patients had evidence of permanent myocardial dysfunction, had a neurologic event, required dialysis, or died within 30 days. [62]

The authors of the Mayo study noted that patients with cold hemagglutinin disease should undergo laboratory testing, including cold agglutinin titers and thermal amplitude, and hematology consultation before cardiac surgery is begun. One patient underwent preoperative plasma exchange. In 2 of 16 procedures that utilized cardioplegia, cold blood cardioplegia was used; in the other procedures, warmer blood cardioplegia was used. One patient experienced cold agglutinin-related postoperative hemolysis requiring transfusion, which was resolved with active warming. [62]

Organs that are used for transplantation (eg, kidneys) are usually kept cool with cold perfusate to preserve organ function. However, if patients with cold agglutinin disease require transplants, the organs may require perfusion with warm solutions before the transplantation, to prevent cold-induced damage by the cold agglutinin present in the recipient.


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