When blood runs cold: cold agglutinins and cardiac surgery

Cold agglutinins are particular cold-reactive antibodies that react with red blood cells when the blood temperature drops below normal body temperature causing increased blood viscosity and red blood cell clumping. Most individuals with cold agglutinins are not aware of their presence, as these antibodies have little effect on daily living, often necessitating no treatment. However, when those with cold agglutinins are exposed to hypothermic situations or undergo procedures such as cardiopulmonary bypass with hypothermia during cardiac surgery, lethal complications of hemolysis, microvascular occlusion and organ failure can occur. By identifying those suspected of possessing cold agglutinins through a comprehensive nursing assessment and patient history, cold agglutinin screening can be performed prior to surgery to determine a diagnosis of cold agglutinin disease. With a confirmed diagnosis of cold agglutinin disease, the plan of care can be focused on measures to maintain the patient's blood temperature above the thermal amplitude throughout their hospitalization including the use of normothermic cardiopulmonary bypass with warm myocardial preservation techniques to prevent these fatal complications. Using a case report approach, the authors review the mechanism, clinical manifestations, detection and nursing management of a patient with cold agglutinins undergoing scheduled cardiac surgery. Cold agglutinin disease is rare. However, the risk to patients warrants an increased awareness of cold agglutinins and screening for those who are suspected of carrying these antibodies.     

Starting out cold

Arriving from St Vincent to start her nurse training in 1958 was a culture shock for Shirla Philogene. But the shock was short lived.     

Non-tuberculosis cold abscess

An 85-year-old cachectic man was found unconscious in his home. He had no specific medical history. On arrival, he was in a deep coma and hypothermic state. He had a soft mass the size of his fist in the right lower abdomen without redness or heat. Truncal computed tomography revealed subcutaneous fluid collection with gas formation. A test puncture for right lower abdominal subcutaneous fluid collection revealed pus, so an open incision was performed, with the administration of broad-spectrum antibiotics. Unfortunately, the patient died of sepsis-induced multiple organ failure. The results of abscess culture later revealed Proteus mirabilis, Escherichia coli, and Prevotella melaninogenica. This is the first report of a cold abscess induced by mixed bacteria.     

Being cold when injured in a cold environment – Patients’ experiences

BackgroundPatients in prehospital care, irrespective of diseases or trauma might experience thermal discomfort because of a cold environment and are at risk for decreasing body temperature which can increase both morbidity and mortality.ObjectiveTo explore patients’ experiences of being cold when injured in a cold environment.MethodTwenty persons who had been injured in a cold environment in northern Sweden were interviewed. Active heat supply was given to 13 of them and seven had passive heat supply. The participants were asked to narrate their individual experience of cold and the pre- and post-injury event, until arrival at the emergency department. The interviews were transcribed verbatim, then analyzed with qualitative content analysis.ResultsPatients described that they suffered more from the cold than because of the pain from the injury. Patients who received active heat supply experienced it in a positive way. Two categories were formulated: Enduring suffering and Relief of suffering.ConclusionThermal discomfort became the largest problem independent of the severity of the injuries. We recommend the use of active heat supply to reduce the negative experiences of thermal discomfort when a person is injured in a cold environment.     

Angina pectoris and cold

Summary

Ten patients with angina pectoris and a history of cold intolerance performed symptom limited work tests at +18d`C and at-17d`C. At -17d`C the work capacity was found to be 20% lower than at+18d`C. In nine of the patients the work load necessary to elicit anginal pain was lower in the cold. Nitroglycerine given before cycling increased the work capacity in the cold to levels obtained in room temperature, mainly due to a decrease in the systolic blood pressure.

Résumé

10 sujets souffrant d'angine de poitrine et présentant une intolérance connue au froid ont effectué un travail à +18d`C et à -17d`C dont l'intensité ne devait pas encore occasionner des symptômes cliniques. A la température de -17d`C, la capacité de travail était de 20% inférieure à celle constatt´e à +18d`C. Dans l'ambiance froide, 9 sujets ont développt´ de l'angor en effectuant un effort normalement bien supportt. L'administration de nitroglycérine avant l'épreuve angomk´trique en chambre froide ríhausse la tolérance à l'effort jusqu'à un niveau enregistre auparavant à température normale. Ceci paraiˇt ětre dû à une baisse de la tension artérielle systolique.

Zusammenfassung

Zehn Patienten mit Angina pectoris und einer Anamnese von Kälteunvertraglichkeit führten symptombegrenzte Arbeits-teste bei Temperaturen von +18d`C und -17d`C aus. Die bei der Temperatur von -17d`C gefundene Arbeitskapazität war 20% niedriger als diejenige bei +18d`C. Bei neun der untersuchten Patienten war die fir die Auslösung eines anginösen Schmerzes notwendige Arbeitsbelastung niedriger in der Kälte als in der Wärme. Nitroglyzerin erhöhte die Arbeitskapazität in der Kälte auf die bei Raumtemperatur registrierten Werte, wenn es vor der Arbeit auf dem Standfahrrad gegeben wurde. Dieser giinstige Effekt beruhte hauptsachlich auf einer Senkung des systolischen Blutdrucks.

Resumen

Diez pacientes con angina de pecho y una historia de intolerancia a1 frio realizaron pruebas de trabajo limitado a los sintomas a +18d`C y a -17d`C. A esta ultima temperatura, se encontró que su capacidad de trabajo era un 20% menor que a la de +18d`C. En nueve casos, la carga de trabajo necesaria para provocar dolor anginoso fue menor con el frio. La nitroglicerina administrada antes del ejercicio en bicicleta aumento la capacidad para el esfuerzo en condiciones frías, a los niveles obtenidos en la temperatura ambiente, principalmente debido a la disminución de la tensión arterial sistólica.