Cold Agglutinins in surgical patients for CABG

[Ardele Hanson]

There is a surgeon here who is pretty insistant that we run a cold agglutinin 'screen' on all his CABG patients before they go in to the OR. This happened because of one patient who exhibited a fairly strong cold agglutinin once the temperatures were lowered in the OR and patient prior to surgery. A cold agglutinin was not found on pre-admit testing in the transfusion service nor in the CBC in hematology. What is a good answer for this guy?

Thanks.

[Liz]

What temperature do you use to detect cold agglutinins and what temperature is used at the OR?

[David Saikin]

There is documentation to back up both sides of this story - the heart surgeon usually get what he wants. We used to do a quck screen - IS, 5'@rt and 5'@4C.

[Ardele Hanson]

Yeah. I did not want to hear that - about the surgeon getting what he wants! But we all know it is true. Why did you "used to a quick screen"? What do you do now? The quick screen might be doable, but the techs will not like it. So, do you do it for the crossmatch or do you include a tube screen along with the crossmatch? And then how is it reported? I imagine we would be requiring a new test in the LIS for resulting?

Thank you so much for your help. This is very helpful.

[Ardele Hanson]

Liz: The cold agg screen is at 4C and the OR lowers the core temp to around 28-30C. There really is no correlation here, I realize that and from what I am reading of late, over 60% of the population will be positive to some degree with a cold panel at 4C. So, the RT incubation (about 23C in our lab) wouldn't even get it.....troublesome in so many ways!!

[David Saikin]

Where I used to work we did open hearts. The pump guys wanted the cold screen and had a paper to back up their request so we did a cold absc for all the hearts (plus the usual). If the screen was positive we did an abid - if a specificity was determined, we tried to provide ag neg rbcs. If you only hit the cells for 5-10 min at 4C, you should not get too many positives. Therre were not that many positives.

[DOGLOVER]

When I worked in the Northeast we did a 15 degree screen for the CABG's. Where I currently work we do not screen for cold agglutinins for open hearts, either adults or pediatrics.

[Yanxia]

The operating room temp will be warmer than our normal lab room remp, I don't think the 4 degree and our room temp will give us anything significant to the operation. I think to do a screen on the operating room temp is ok.

[Malcolm Needs ☆]

Agree 100% shily.

[Bill]

Since there is no FDA or AABB approved test at the temperature stated for the surgery area, would this then become a "home brew" test as defined by the FDA and require all the bull s**t associated with using the test? That would be far more than just validating the test.

[KBBB]

The OR suites at the hospital I used to work at were much colder than usual Rm Temp. We had to do a 4 deg. and 22 deg. 15-20 min incub. screen...2 drop patient plasma, 1 drop patient cells. If the result was 2+ or greater (if I remember right), we had to call the OR. We just wrote them on a log since we couldn't figure out how to do this in the computer system without causing issues. This mandate was from the head (and big Kahuna) of Cardiac Surgery. We also had a reference in our file from the Dr. and he had some personal bad experience.

[marvy1]

John Moulds wrote a one-page QandA on this topic in the AABB news (Jan 2010). In sum: don't go looking for a cold ab...if it shows up in the ABORh testing for a cardiac case, there may be use in doing a 28 or 32C thermal range test (as well as the regular 37C). 4C testing is pretty much useless as most everyone reacts at that temp.