What preoperative measures should be taken for a patient with Immune Thrombocytopenic Purpura (ITP) who has failed medical management and is referred for splenectomy?

Preoperative Measures for ITP Patients Undergoing Splenectomy

Prior to splenectomy for ITP patients who have failed medical management, vaccination against encapsulated organisms should be administered at least 4 weeks before surgery (preferably) or 2 weeks after if not done preoperatively. 1

Required Preoperative Vaccinations

• Polyvalent pneumococcal vaccine should be administered to protect against Streptococcus pneumoniae 1
• Meningococcal C conjugate vaccine should be given to prevent Neisseria meningitidis infection 1
• Haemophilus influenzae b (Hib) vaccine should be administered to protect against this encapsulated organism 1

Preoperative Testing and Evaluation

• Test patients for HCV and HIV infection, as these can cause secondary ITP and may influence management decisions 1
• Consider screening for H. pylori infection, as eradication therapy should be administered if positive before proceeding with splenectomy 1
• Further investigations should be performed if there are abnormalities in the blood count or smear (other than thrombocytopenia or findings of iron deficiency) 1
• A bone marrow examination is not necessary in patients presenting with typical ITP 1

Preoperative Platelet Count Management

• For patients with severely low platelet counts, preoperative therapy to increase platelet counts may be necessary 2
• Options for raising platelet counts before surgery include:
  • Corticosteroids: Should be administered before surgery; most patients respond with increased platelet counts 2
  • Intravenous immunoglobulin (IVIg): Can be used with a dose of 1 g/kg as a one-time dose, which may be repeated if necessary 1
  • Anti-D (in appropriate patients): Can be considered as an alternative to IVIg if corticosteroids are contraindicated 1

Surgical Approach Considerations

• Both laparoscopic and open splenectomy offer similar efficacy for medically suitable patients 1
• The choice between laparoscopic and open approaches should be based on patient factors and surgeon expertise 1

Patient Education

• Patients should be educated about the risk of post-splenectomy infection 1
• Patients should be instructed to seek immediate medical attention if fever higher than 101°F (38°C) occurs 1
• Patients should be advised to carry medical alert cards indicating their asplenic status; some may benefit from alert bracelets or pendants 1

Antibiotic Prophylaxis Planning

• Arrange for patients to have a home supply of antibiotics (e.g., penicillin VK, erythromycin, or levofloxacin) for use in case of febrile illness 1
• Consider whether long-term antibiotic prophylaxis is appropriate for the individual patient, though consensus on this practice has not been reached 1

Timing Considerations

• If possible, splenectomy should be delayed for at least 12 months after diagnosis to allow for spontaneous or therapy-induced remissions, particularly in older patients who have increased surgical morbidity and lower rates of response 3
• Patients with prolonged medical therapy (>6 months) before splenectomy may have higher postoperative complication rates 4