Spinal Anesthesia in a Patient With Cold Agglutinin Disease Presenting for Total Knee Arthroplasty in a Community Hospital Setting

Idiopathic cold agglutinin disease is a form of autoimmune hemolytic anemia (AIHA) characterized by autoantibody-mediated red blood cell (RBC) agglutination and hemolytic anemia at colder temperatures. Due to the increased risk of clinical manifestations of this condition at cold temperatures, this condition presents unique thermoregulatory considerations perioperatively. There is a risk of hypothermia in patients who undergo both general and regional anesthesia due to impairments in thermoregulatory control. However, there is a paucity of literature detailing perioperative considerations for this patient population who undergo neuraxial anesthesia. In this report, the physiology of perioperative hypothermia and the thermoregulatory impairments seen in both general and neuraxial anesthesia are reviewed. This case report details the perioperative management and warming strategies for an 83-year-old female with a history of idiopathic cold agglutinin disease who underwent spinal anesthesia for an elective primary total knee arthroplasty (TKA) in a community hospital setting. This report demonstrates that under a strict temperature management strategy, either spinal or general anesthesia may be considered for this patient population. Pre-operative optimization, stability of symptoms, the frequency of laboratory monitoring required, and the need for rapid cold agglutinin-directed therapy influence the decision as to whether these cases can be safely performed in an ambulatory community hospital setting versus a tertiary care center.