A 65-year-old woman with severe cold agglutinin disease (CAD) experienced a successful perioperative period when having a total hip arthroplasty with a cemented stem. The case was recently reported in A&A Practice.

The clinical team kept the temperature of the operating room at 28 °C and took extra care in covering the patient when transferring her from the ward to the operating room. At the time she entered the operating room, her axillary temperature was 35.8 °C. So the team used a forced-air warming system to raise her temperature to 36.8 °C before proceeding with anesthesia.

“Particular attention must be paid to temperature control in patients with high titers of cold agglutinins, since general anesthesia causes hypothermia due to exposure to a cold environment and anesthetic-induced impaired thermoregulation, which causes vasodilation, inhibits vasoconstriction, and reduces the metabolic rate by 20% to 30%,” the clinical team explained. “In the present case, we set the ideal body temperature to >37 °C because the patient never reported symptoms of Raynaud’s disease at 36.5 °C in her daily life.”

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Additional multimodal warming strategies adopted during surgery included heating the gas administered through the ventilator to 38 °C, heating all infusions to 40 °C, and using the forced-air warming system, as well as gloves and socks, to preserve the patient’s temperature. Moreover, the patient received a prewarmed infusion of amino acids, which has been shown to prevent perioperative hypothermia, prior to and during surgery. The bone cement used for surgery was at room temperature.

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Blood loss during surgery led to hemorrhagic shock, which was managed by extracellular fluid and red blood cell administration. The patient’s blood pressure remained temporarily unstable and she had to receive additional extracellular fluid and red blood cells. However, she did not develop hypothermia, symptoms of Raynaud’s disease, elevated lactate dehydrogenase or bilirubin levels, or hematuria due to hemolysis.

The postoperative course went smoothly and the patient was discharged on postoperative day 11.


Yamaguchi T, Hirate H, Kusano T, Inagaki Y. Perioperative management of a patient with severe cold agglutinin disease undergoing total hip arthroplasty with a cemented stem: a case report. A&A Pract. 2022;16(12):e01647. doi:10.1213/XAA.0000000000001647