cold agglutinins and blood/cardioplegia solutions

[jsocolow]

We have been approached by our Perfusion team to do a Cold Agglutinin assessment for every patient going on bypass. What test do you do, if any, and at what temperature? The literature suggests if it's active at room temp, it may be significant, but with new techniques they are using in the Perfusion arena, they are saying that they are seeing alot more "clumping" in the bypass tubing with patients on whom we have no detectable cold agglutinins by our routine testing. We currently test by automated Capture Methodology, and perform the bulk of our xm's by electronic xm for all who qualify. Typically, if there is a strong cold agglutinin, we get errors on our ABO testing by automation. Thanks for your input!

[dmpollock]

Your current method will not pick up most cold agglutinins in group O patients.

We had a problem with this and it turned into the Spanish Inquisition. I still refer to this as the "Cold War" which started more than two years ago. After several months of turmoil we are now in a state of dètente.

I never did find a published procedure for this. My only "revenge" for having to do this was to use a single reference, an article by John Judd, "How I Manage Cold Agglutinins," that states:

Cold agglutinins and heart surgery

There are conflicting opinions expressed in surgical journals. Our approach is “don’t screen for them; don’t report them.” We discourage requests for titration and thermal amplitude tests and recommend use of room temperature crystalloid instead of cold cardioplegia.

Here is what we ended up with:

Cold Agglutinin Screen

Principle and Clinical Significance

Principle - An autocontrol tube is tested at room temperature for cold agglutinins. If agglutination is found at room temperature the sample is retested at approximately 4° and 15° C.

Clinical Significance - Cold agglutinins may cause problems during open heart surgery when the patient's body or blood temperature is lowered to nonphysiologic temperatures.

Specimen

• See Specimen Acceptance procedure.
  
• The specimen must not be refrigerated prior to testing. If refrigerated, a new sample must be collected.
  

Reagents

• Isotonic saline
  

Equipment and Supplies

• 12 x 75 mm test tubes
  
• Calibrated centrifuge
  
• Ice
  
• Dishpan
  
• Test tube rack
  
• Indelible marking pen
  
• Calibrated thermometer
  

Quality Control

Reagents must be tested each day of use with appropriate controls. See Daily Quality Control tprocedure.

Procedure

Cold Agglutinin Screen

1. Label two tubes with patient/unit and test identification as described in the Tube Labeling procedure. One tube will be needed for the patient's cells and one for the autocontrol.
   
2. Prepare a 3-4% suspension of patient cells for testing, as described in the Preparation of Cell Suspensions for Testing procedure.
   
3. Add two drops of patient serum to the autocontrol tube.
   
4. Add one drop of 3-4% patient cells to the autocontrol tube.
   
5. Mix well and centrifuge the test tubes for the amount of time specified on the Serofuge (usually 15 seconds).
   
6. Resuspend and read for agglutination. Grade and record test results immediately ("Immediate Spin" reading).
   
7. Incubate at room temperature 10 minutes.
   
8. Centrifuge the test tubes for the amount of time specified on the Serofuge.
   
9. Resuspend and read for agglutination. Grade and record test results immediately ("RT 10'" reading).
   
10. If the room temperature result is positive at either immediate spin or after incubation, perform the "thermal amplitude test."
    

Thermal Amplitude Test

1. Set up a 15°C water bath (Wet Ice in a basin covered with tap water). The temperature will be an approximation.
   
2. Label two tubes. One tube will be needed for the 15°C test and one for the for the 4°C test.
   
3. Place 1 Auto tube in the 15°C basin.
   
4. Place the 4°C tube into Serofuge Carrier Head & place it in a refrigerator at 4°C.
   
5. Incubate for 10 minutes.
   
6. Centrifuge the test tubes for the amount of time specified on the Serofuge.
   
7. Resuspend and read for agglutination. Grade and record test results.
   

Reference

Judd, John W, How I manage cold agglutinins. Transfusion 2006;46:324-326.

Edited April 18, 2013 by dmpollock

[Yanxia]

Thanks for dmpollock .

I think the 4 degree seems no need, because the tempe of patient during surgery will not low to this .

And if during surgery, there is need transfusion, it is better to do a cold antibody screen use screening cells at parellel with autocontrol.

Just my thought.

[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.

 

Malcolm Needs also replied in a similar topic thread back in Feb: 

 

There has just been a reveiw paper published on the is very subject.

Jain MD, Cabreeizo-Sanchez R, Karkouti K, Yau T, Pendergrast JM, Cserti-Gazdewich CM. Seek and You Shall Find - But Then What Do You? Cold Agglutinins in Cardiopulmonary Bypass and a Single-Center Experience With Cold Aglutinin Screening Before Cardiac Surgery. Transfusion Medicine Reviews 2013 http://dx.doi.org/10...mrv.2012.12.001.

Basically, it says that doing such screens before surgery is a waste of money!

[Malcolm Needs ☆]

 

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.

 

Malcolm Needs also replied in a similar topic thread back in Feb: 

 

There has just been a reveiw paper published on the is very subject.

Jain MD, Cabreeizo-Sanchez R, Karkouti K, Yau T, Pendergrast JM, Cserti-Gazdewich CM. Seek and You Shall Find - But Then What Do You? Cold Agglutinins in Cardiopulmonary Bypass and a Single-Center Experience With Cold Aglutinin Screening Before Cardiac Surgery. Transfusion Medicine Reviews 2013 http://dx.doi.org/10...mrv.2012.12.001.

Basically, it says that doing such screens before surgery is a waste of money!

 

 

AGREED (in upper case letters)!!!!!!!!!!!!!!!!!!!!