Post-Splenectomy Care

OVERVIEW

Post-splenectomy patients

  • are at increased risk of infection from encapsulated organisms which can (very rarely) lead to overwhelming post-splenectomy sepsis (OPSS)
  • have distinctive findings on full blood count (FBC) and the blood film

CAUSES OF INFECTION

Important causative organisms post-splenectomy:

  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Neiserria meningitidis
  • Capnocytophaga canimorsus
  • Salmonella spp
  • Malaria
  • Babeosis

INVESTIGATIONS

FBC/ blood film abnormalities observed post-splenectomy:

  • leukocytosis (acutely)
  • thrombocytosis
  • Howell-Jolly bodies (nuclear fragments within red cells normally removed by spleen)
  • pitted red cells
  • target cells
  • basophilia
  • Heinz bodies (indicates oxidative stress)

MANAGEMENT

Overview

  • Usual acute post-operative care, including supportive care and monitoring for post-operative complications
  • Specific management required for post-splenectomy patients (see below)
  • In Victoria, Australia, patients can be placed on a Splenectomy Registry to help ensure appropriate followup

Immunisation (boosted every 5 years)

  • Pneumococcal
  • HiB
  • Meningococcal C
  • Influenza

Prophylactic antibiotics (advice largely based on data from children with sickle cell anaemia, little evidence in adults)

  • e.g. amoxicillin
  • children less than 5 years of age with sickle cell anaemia (functionally asplenic)
  • at least 3 years following splenectomy (some experts advise no antibiotics in an otherwise well adult)
  • asplenic patients with severe underlying immunosuppression
  • at least 6 months after an episode of severe sepsis in asplenic patients

Fever management

  • must have a prescription for empiric antibiotics ASAP (e.g. amoxicillin-clavulanate, cefuroxime, moxifloxacin, ceftriaxone)
  • must seek medical attention ASAP

Advice

  • Asplenic patients should carry a medical alert and an up-to-date vaccination card
  • Asplenic patients require specific advice on travel as they are at increased risk of severe malaria (mosquitoes) and babeosis (tick bites) in endemic areas
  • Asplenic patients require specific advice about animal handling as OPSS (due to Capnocytophaga canimorsus) may result from dog, cat or other animal bites

Other

  • post-splenectomy thrombocytopenia
    • usually transient but can be marked
    • If >1,000 x 10e9/uL Aspirin 100mg daily po

TIMING OF POST-SPLENECTOMY IMMUNISATION

This is controversial

  • No difference in antibody titre is observed whether vaccinated on Day 1, 7 or 14, but better functional activity is observed when vaccinated at Day 14. However, this conclusion is based on laboratory results, not clinical outcomes.
  • A splenectomised rat study demonstrated no difference in clinical outcome with vaccination on Day 1, 7 or 42 with subsequent intraperitoneal inoculation with pneumococcus, but a much greater mortality if not vaccinated at all.
  • There is no good data at all on vaccine administration after angioembolization. Animal studies suggest that at least 50% of the spleen must be perfused by the splenic artery in order to maintain immune competence.
  • Practice varies in different centres
  • Timing is less important than ensuring that the patient does actually get vaccinated!

References and Links

Journal articles

  • Shatz DV, Schinsky MF, Pais LB, Romero-Steiner S, Kirton OC, Carlone GM. Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma. 1998 May;44(5):760-5; discussion 765-6. [pubmed]
  • Spelman D, Buttery J, Daley A, Isaacs D, Jennens I, Kakakios A, Lawrence R, Roberts S, Torda A, Watson DA, Woolley I, Anderson T, Street A; Australasian Society for Infectious Diseases. Guidelines for the prevention of sepsis in asplenic and hyposplenic patients. Intern Med J. 2008 May;38(5):349-56. [pubmed]

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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