Warming strategies prevent surgical complications in woman with CAD
Woman, 42, undergoes hysterectomy without CAD-related complications
Warming strategies to prevent body temperature from dropping enabled a 42-year-old woman with cold agglutinin disease (CAD) to undergo a hysterectomy under general anesthesia without any disease-related complications, a study shows.
“Comprehensive strategies — including measures to promote heat production, maintain core temperature, and prevent redistributive hypothermia — are necessary for perioperative thermal management of patients with CAD,” researchers wrote.
Redistributive hypothermia, which often occurs under anesthesia, refers to a drop in the body’s temperature when warm blood from the body’s core moves to the limbs and skin. The perioperative period refers to the time around surgery.
The case was described in the study “Anesthetic Management During Total Abdominal Hysterectomy in a Patient With Cold Agglutinin Disease: A Case Report,” which was published in Cureus.
In CAD, a specific type of self-reactive antibodies, called cold agglutinins, bind to red blood cells at cold temperatures, causing them to clump together and die, in a process known as hemolysis. This results in low counts of red blood cells (anemia), which cannot efficiently carry oxygen throughout the body, leading to fatigue and other disease symptoms.
CAD patients at higher risk for surgical complications
Because CAD symptoms worsen at low temperatures, patients are at a higher risk of complications during major surgeries, when the operating room can be too cold and the body’s core temperature can get too low under general anesthesia.
“Therefore, maintaining warmth by preventing heat loss from the body surface is crucial to preventing hemolytic episodes in patients with CAD under general anesthesia,” the researchers wrote.
In the report, a team of researchers in Japan described the case of a woman with CAD who safely underwent full abdominal hysterectomy, or surgery to remove the uterus, without CAD-related complications.
The woman was admitted to hospital after several days of experiencing lower abdominal pain and irregular genital bleeding, and a worsening in her condition which included breathing issues, dizziness, and movement difficulties.
Comprehensive examination showed the presence of large uterine fibroids, which are benign tumors that grow in the uterus, and she was scheduled to undergo a hysterectomy.
Blood tests showed low levels of red blood cells and hemoglobin, the protein that carries oxygen in red blood cells, and elevated levels of bilirubin, a marker of hemolysis. Further testing detected high levels of cold agglutinins, leading to a diagnosis of CAD. The woman did not report any previous CAD symptoms.
The woman received a blood transfusion to restore her hemoglobin levels.
While large uterine fibroids can also cause anemia, the presence of CAD could not be ruled out as a potential cause. As such, strict temperature management during surgery was planned due to concerns about heat loss and the potential to trigger hemolysis.
On the day of the surgery, the patient received an into-the-vein infusion of a standard mixture of amino acids (the building blocks of proteins) over two hours to help maintain body temperature.
Amino acid infusions prevent decreases in body temperature due to several mechanisms, including a direct action on the temperature control center of the brain and an increase in protein production in muscles that increases heat production.
The woman received general anesthesia in addition to thoracic epidural anesthesia, which is administered to the spine in the mid-back region. Her body temperature was monitored via the rectum and armpit.
Operating room, fluids used were warmed
During the surgery, the room temperature was set to 30 C (86 F), and the woman’s upper body was warmed with a forced-air warming device. Also, all fluids administered to her bloodstream during surgery were warmed.
Her body temperature remained stable during surgery, even showing an upward trend after she was started on anesthesia.
“The presence of an upward trend — rather than a decline — in both core and surface temperatures may suggest that metabolic heat production exceeded heat loss, an effect we believe was likely attributable to the thermoregulatory benefits of the amino acid infusion,” the researchers wrote.
No signs of hemolysis or other cold-induced CAD complications were reported. The woman lost nearly 1 L of blood during the procedure and received a total of 2.25 L of fluids.
One day after the procedure, her hemoglobin levels had dropped, which the researchers attributed to bleeding during the surgery and the fluid infusion. Her hemoglobin levels were normalized with oral iron supplements (iron is essential for hemoglobin production).
She recovered from the surgery without complications or signs of hemolysis, and was discharged eight days after the surgery.
“Our case of a patient with CAD demonstrated that general anesthesia for total abdominal hysterectomy could be successfully performed without perioperative complications by implementing strict and comprehensive measures to monitor and control body temperature,” the researchers concluded.
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