Ambulatory total knee arthroplasty in a patient with cold agglutinin disease

Cold agglutinin disease (CAD) is a rare autoimmune disease caused by high titres of cold-reacting autoantibodies that cause red blood cell agglutination and subsequent hemolysis at low temperatures. Trauma, surgery, and infection/inflammation exacerbate CAD. The present report describes the successful perioperative management of a patient with CAD who underwent outpatient total knee arthroplasty (TKA).

A 70-yr-old female was diagnosed with CAD in 2016 with symptoms of pain and pallor in her fingertips, numbness and bluish discoloration of her tongue, and shortness of breath. She was treated with folic acid, rituximab, and bendamustine. After remaining symptom-free for 4 yrs and following consultation with hematology, she was scheduled to undergo TKA. She received a spinal anesthetic with chloroprocaine, intravenous sedation, antiemetic prophylaxis, and an adductor canal catheter for continuous perineural analgesia. Warming measures, including a warm (20 °C) operating room, warm intravenous fluids, warm irrigating fluids, warm surgical prepping solution, forced-air warming blankets, and avoidance of a thigh tourniquet, helped prevent hypothermia in the patient. The patient's perioperative course was uneventful, and she was discharged on the same day. She was followed up via a patient monitoring mobile application and advised to monitor herself for signs of CAD relapse. She had no concerns up to three months after surgery.

The perioperative management of patients with CAD is challenging, and multidisciplinary collaboration and coordination between the anesthesiologist, surgeon, hematologist, and nurses, as well as adequate intraoperative precautions and postoperative instructions and monitoring, are essential to ensuring safe surgery and optimal patient outcomes.