Preoperative:

        • Since most of the IgM is intravascular, some authors have proposed the use of plasma exchange with fresh frozen plasma [4,8-11].

        • Determine the specific cold agglutinin thermal-range to guide intraoperative hypothermic limit [8,9].

        • Titer levels and hematology consult might be beneficial [1,8,10].

        • Patients with very low hemoglobin levels might require transfusions of RBCs and/or erythropoietin to optimize oxygen carrying capacity [7,8,11].

        • Maintain normothermia [1,4,8].

Intraoperative:

        • Use of warmed products, including bypass priming fluids, blood products, intravenous fluids and anesthetic gases [1,4,8-10].

        • Using body-warming blankets and elevation of operating room temperature [1,4,8,10].

        • Intraoperative monitoring of core body temperature to continuously stay above the reactive thermal amplitude of the CA antibodies [4,10].

        • Cardioplegia and CBP modifications

        • Maintain normothermia or moderate hypothermia above the thermal range [8,10].

        • Avoidance of cardioplegia [1,8,12].

        • Use warm blood cardioplegia [2,3,8,9].

        • Complete coronary and cardiac washout with intermittent cold crystalloid [9,11-14].

        • Cold blood cardioplegia in patients with CA and low thermal amplitudes [8].

        • If cold agglutinin disease is discovered intraoperatively

        • Return patient to normothermia or to moderate hypothermia [8,13].

        • Use of warm blood cardioplegia [8,10].

        • Switch from blood to cold crystalloid cardioplegia (may provide inferior myocardial protection) [8,10].

Postoperative

        • Keep the patient warm at all times [4,8].

        • Be vigilant for symptoms and signs of possible end organ damage [9].

        • Transfuse as needed [4,8].