Perioperative management of cold agglutinin autoimmune hemolytic anemia in an older adult undergoing radical cystectomy for bladder cancer

Abstract

Patients diagnosed with bladder cancer are most frequently older adults who have multiple chronic conditions. Frequently, new conditions are unmasked during preoperative evaluation for surgery such as radical cystectomy. We report the case of an 85 year old male with muscle invasive bladder cancer who was concurrently diagnosed with cold agglutinin hemolytic anemia. This case demonstrates the importance of close attention to underlying chronic conditions in older adults considering major cancer surgery and the need for multidisciplinary management in medically complex cases.

Deep Hypothermic Circulatory Arrest for Emergency Repair of Type A Aortic Dissection in a Patient with Cold Agglutinins

“…Identification of high-risk individuals involves questioning about signs and symptoms of hemolysis and agglutination (14). High-risk patients would benefit from obtaining titers, determining TA, and obtaining a hematology and/or anesthesiology consultation (3,4,14). If titers are as low as ,1:40 and TA is ,20 C, no further workup is needed (3,4).…”

“…High-risk patients would benefit from obtaining titers, determining TA, and obtaining a hematology and/or anesthesiology consultation (3,4,14). If titers are as low as ,1:40 and TA is ,20 C, no further workup is needed (3,4). Management strategies include reduction of antibody levels through plasma exchange, administration of steroid, azathioprine, cyclophosphamide, or rituximab, in an effort to mitigate the likelihood of clinical significance (3,4).…”

“…Cold agglutinin disease (CAD) is a rare clonal lymphoproliferative B-cell bone marrow disorder that results in an autoimmune hemolytic anemia in the setting of cooler temperatures (1)(2)(3). Though uncommon, it accounts for 15-25% of autoimmune hemolytic anemias and is observed more in Northern Europe, with a prevalence of 13-16 per million individuals (2,4,5).…”

“…Although CAD is rare and largely asymptomatic, CAD becomes pertinent in rare clinical situations, such as deep hypothermic circulatory arrest (DHCA) and cardiac surgery when hypothermia induces CA (1)(2)(3)(4)(5)(6). It can be potentially catastrophic if not detected early, leading to complications associated with cardiopulmonary bypass (CPB) resulting from agglutination and hemolysis (1,2).…”

Microvascular free tissue transfer in the setting of cold agglutinin disease

“…Organ allotransplantation is also associated with thrombosis due to thrombosis in CAD. Studies have previously described the management of patients with CAD who need to undergo cardiac surgery, abdominal surgeries and dental procedures (Barbara et al, 2013;Cho & Kumar, 2019;Southern et al, 2019). Measures to reduce the risk of microvascular occlusion and thrombosis include flushing the organ with warmed saline and topical warming and with this, success can be achieved (Leung et al, 2021).…”