Key Steps Can Lower Risk of CAD Complications During Surgery

The case of an 80-year-old man with cold agglutinin disease (CAD) who underwent abdominal surgery to remove his gallbladder was described in a recent report.

Its investigators highlighted steps that can be taken to minimize the risk of CAD-related complications during surgery, such as increasing the temperature of the operating room and placing warmers under the patient’s body.

The case study, “Perioperative considerations in the management of cold agglutinin disease in laparoscopic surgery,” was published in the journal BMJ Case Reports.

CAD is an autoimmune disorder in which self-reactive antibodies bind and destroy red blood cells at low temperatures, resulting in anemia. Previous studies suggest that trauma, surgery, and infection can further worsen CAD symptoms and lead to potentially life-threatening complications.

Specific measures in such instances, however, can be adopted to avoid CAD worsening.

The 80-year-old man went to a hospital in Boston with complaints of abdominal pain, lost appetite, and vomiting. Imaging tests revealed that the patient’s gallbladder — the pouch-like organ that sits just under the liver and stores bile, a substance needed for digestion — was swollen.

Laboratory tests also revealed high levels of proteins related to heart damage, as well as a bacterial infection.

Because doctors suspected that the patient might be experiencing a heart attack, he was transferred to the hospital’s cardiac unit. He was given antibiotics for the infection.

Within the cardiac unit, the patient experienced changes in his mental status, at one point “resulting in him no longer speaking English, answering only in German and Bengali,” according to the investigators.

At the same time, his levels of hemoglobin — the protein in red blood cells that transports oxygen — decreased substantially, from 104 g/L to 68 g/L. This prompted a blood transfusion, to which the patient reacted badly to by developing wheezing and a blotchy rash. The transfusion was stopped, and further lab tests were ordered.

Among the results of those tests were a positive Coombs test, one of the diagnostic tests for CAD that specifically looks for the self-reactive antibodies that cause the disease. Further testing confirmed the CAD diagnosis.

Physicians then gave the man another blood transfusion — this time with fluid warming — that was well-tolerated.

To manage his swollen gallbladder, a percutaneous cholecystostomy tube was placed. This tube is essentially placed into the gallbladder through the skin, allowing for excess liquid in the gallbladder to drain. The gallbladder was successfully drained, but because there is a relatively high (20–30%) risk of complications from gallstone disease after the tube is removed, the patient and his healthcare team decided to proceed with surgical removal of the gallbladder, referred to as interval cholecystectomy.

During surgery under anesthesia, the body’s temperature tends to drop, which can increase the risk of CAD complications.

“In light of the patient’s diagnosis of cold agglutinin disease, preoperative efforts were made to optimise the safety of the [surgical] procedure. A discussion was held between the anaesthesia, surgical, haematology and nursing teams to determine how best to proceed with the surgery to avoid exacerbating the patient’s cold agglutinin disease,” the researchers wrote.

Among the steps implemented, the team decided to keep the operating room at a warmer temperature, and to place a bed warmer under the patient’s body during surgery. They also ensured that any fluids infused during surgery were warmed beforehand.

Prior to surgery, a variety of blood tests were performed, and during surgery, the patient’s body temperature was consistently monitored.

During surgery, his hemoglobin levels started to drop — from 85 g/L before surgery, to 74 g/L, and then to 70 g/L —, requiring the patient to be admitted to the hospital after surgery. His hemoglobin levels dipped as low as 62 g/L, requiring physicians to administer another warmed blood transfusion, after which his hemoglobin levels rose to 72 g/L.

Some complications followed the surgery (e.g., fevers), but the man was eventually discharged from the hospital after remaining in observation for several days. Two weeks after being discharged, his hemoglobin level was at 71 g/L.

“This report highlights management strategies of cold agglutinin disease within the operating room,” the researchers concluded, noting that “the mainstay of treatment is ensuring patients remain warm.”