Warming methods during surgery safe for elderly woman with CAD
Researchers: Case shows importance of 'preoperative' efforts for patients
An 83-year-old woman with cold agglutinin disease (CAD) had knee surgery under local spinal anesthesia without any disease-related complications as a result of significant warming strategies to prevent her body temperature from getting too low, a study shows.
During and after the surgery, the woman’s body temperature remained stable and she didn’t show any signs of red blood cell destruction, called acute hemolysis and a hallmark of CAD.
“This case highlights the importance of preoperative optimization of patients with [CAD], with special attention paid to disease severity and the risk of acute exacerbation with worsening hemolysis,” the researchers wrote. The case study, “Spinal Anesthesia in a Patient With Cold Agglutinin Disease Presenting for Total Knee Arthroplasty in a Community Hospital Setting,” was published in Cureus.
CAD is caused by cold agglutinins, specific types of self-reactive antibodies that bind to red blood cells at cold temperatures, causing them to clump together and be destroyed. This leads to the formation of blood clots and anemia, or low levels of red blood cells to transport oxygen, that can lead to fatigue and other CAD symptoms.
During surgeries, when anesthetics and skin being exposed can cause the body temperature to drop, CAD patients are at a higher risk of disease-related complications, including acute hemolysis. Therefore, rigorously controlling body temperature and warming measures are crucial to reduce risks.
Warming methods to prevent CAD symptoms
In this case, the woman, who had a longstanding history of CAD, underwent a robotic-assisted knee surgery under spinal anesthesia without any CAD-related complications, according to a trio of researchers at the Mayo Clinic in Minnesota. The surgery, which was conducted at a community hospital, was to replace a knee damaged by osteoarthritis, a condition that causes degeneration of joint cartilage and underlying bone.
The woman also had high blood pressure, chronic hepatitis B (a viral infection that causes liver inflammation), and previous episodes of hemolysis-related anemia, which were treated with intravenous immunoglobulin (IVIG), glucocorticoids, and rituximab. IVIG involves administering healthy antibodies to neutralize the self-reactive antibodies that drive CAD, while glucocorticoids and rituximab suppress the immune system.
Lab results on cold agglutinins, from three years before the knee surgery, showed high levels.
A year before the surgery, the woman had a severe episode of hemolytic anemia due to a bacterial infection that spread to the bloodstream and required several blood transfusions. Her blood levels of hemoglobin, the protein in red blood cells that transports oxygen, remained stable after her discharge and she was followed regularly. A month before the surgery, blood levels of hemoglobin and reticulocytes, or immature blood cells that typically increase with CAD-related hemolysis, were within usual levels.
The surgery was conducted under spinal anesthesia and significant efforts were made during it to prevent hypothermia, or abnormally low body temperature, and hemolysis using ambient and forced air heating methods. Specifically, the woman was warmed ahead of the surgery with a warming gown with forced air at 42 C (107.6 F), and “an underbody forced-air warmer was placed on the operating table and used for the spinal procedure and throughout the operation,” the researchers wrote.
Also, warm blankets were draped over her shoulders and head ahead of the placement of the needle for the spinal anesthesia, and the solution used to prepare her skin for the needle and the anesthetic solution (2% mepivacaine) were warmed before administration. After the needle was placed, she was covered with an over-body forced air warmer and her head was wrapped in a warmed blanket.
During the surgery, fluids administered directly into the bloodstream, including propofol for continuous sedation, were warmed to 41 C (105.8 F) and the room temperature was maintained at 23 C (73.4 F).
The total time in the operating room was 95 minutes, or about 1.5 hours, during which her body temperature remained stable. The woman lost about 100 mL of blood during the procedure. She recovered from the surgery without complications or signs of acute hemolysis and was discharged the following day.
At her one-month follow-up, her hemoglobin and reticulocyte levels remained within her usual values, and the woman didn’t show any CAD symptoms.
The case shows that “spinal anesthesia can be employed with aggressive warming techniques, continuous noninvasive temperature monitoring, and within an ambulatory setting with immediate access to escalating care services if needed,” the researchers wrote.
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