George, Melissa R

Herman, Jay

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Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Pathology, Anatomy and CellBiology Faculty PapersDepartment of Pathology, Anatomy and CellBiology12-2013Transfusion medicine illustrated: Transfusioninterference by cold agglutinins.Melissa R. GeorgePenn State M.S. Hershey Medical CenterJay HermanThomas Jefferson University, jay.herman@jefferson.eduLet us know how access to this document benefits youFollow this and additional works at: http://jdc.jefferson.edu/pacbfpPart of the Pathology CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Pathology, Anatomy and Cell Biology Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For moreinformation, please contact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationGeorge, Melissa R. and Herman, Jay, "Transfusion medicine illustrated: Transfusion interference bycold agglutinins." (2013). Department of Pathology, Anatomy and Cell Biology Faculty Papers. Paper177.http://jdc.jefferson.edu/pacbfp/177Transfusion interference by cold agglutinins  Melissa R. George and Jay H. Herman  Transfusion of an autologous unit of CPDA-1 whole blood was attempted for a 57-year-old woman after total knee arthroplasty. The patient had no other significant medical history other than severe osteoarthritis. She had requested banking a unit of autologous blood because she felt that it was safer than allogeneic blood. After surgery, the patient was transfused while she was recovering in the PACU for higher than normal amounts of bloody wound drainage. The autologous unit was hung without a blood warmer within 10 minutes after removal from the refrigerator. Flow alarms indicated an occlusion and an apparent clot was noted; this was not noticed upon retrieval of the unit from the blood bank refrigerator and the clot may have been dispersed by mixing during handling. The transfusion was stopped and the unit was returned to the blood bank. Upon inspection there were no grossly visible clots or hemolysis (see figure, left) but by this time the unit had been at room temperature for several hours. The presence of a cold agglutinin was suspected, and the unit was placed in the refrigerator and reevaluated the next day. A large aggregation of RBCs, which could not be separated by kneading, was evident (see figure, right). Plasma from the unit was sent for PT, aPTT, INR, fibrinogen, and D-dimer testing and all results were within normal limits with the exception of a slightly elevated PT of 18.2 seconds (normal, 11.1–15.5 sec). The “clot” was observed to disperse after the unit was again warmed to room temperature. An antibody screen using PEG-AGT tube method showed no reactivity at room temperature immediate spin but reactivity at 4°C was consistent with a cold agglutinin. Immediate-spin cross-matches were negative and the patient’s forward and reverse typing were valid as Group A, which argued against a cold agglutinin. Due to this inconsistency, a separate autocontrol at 4°C was performed that demonstrated reactivity. Automated CBC results demonstrated no abnormalities and a peripheral smear was not examined at the time.  This fits the clinical scenario of a cold agglutinin causing occlusion of the infusion set rather than a true clot. We informed the patient’s physician of the findings and recommended use of a blood warmer for future autologous transfusions. Cold agglutinins are common and often found in normal individuals. They are generally clinically irrelevant, but can be a nuisance in blood testing and in blood administration, as in this case. Prewarming tech- niques and omission of immediate-spin room temperature testing may prevent detection of cold agglutinins and other clinically insignificant cold antibodies. Use of an autolo- gous unit of RBCs rather than whole blood could also miti- gate the effects of a cold agglutinin as there would be less plasma volume and, thus, less cold agglutinin.   From the Penn State M.S. Hershey Medical Center, Hershey, Pennsylvania; and Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.  Address reprint requests to: Melissa R. George, DO, Department of Pathology, Penn State M.S. Hershey Medical Center, 500 University Drive, H-160, P.O. Box 850, Hershey, PA 17033; e-mail: mgeorge5@hmc.psu.edu.  doi: 10.1111/trf.12286  TRANSFUSION 2013;53:3036.  3036 TRANSFUSION Volume 53, December 2013  CONFLICT OF INTEREST  The authors declare no conflicts of interest.   

Transfusion medicine illustrated: Transfusion interference by cold agglutinins.

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Transfusion medicine illustrated: Transfusion interference by cold agglutinins.

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