What is the postoperative care for a 5-year-old who underwent splenectomy due to hereditary spherocytosis?

Postoperative Care for Splenectomy in a 5-Year-Old with Hereditary Spherocytosis

A 5-year-old child undergoing splenectomy for hereditary spherocytosis requires immediate postoperative vaccination (if not given preoperatively), lifelong antibiotic prophylaxis with phenoxymethylpenicillin, annual influenza vaccination, and comprehensive family education about the lifelong risk of overwhelming post-splenectomy infection (OPSI). 1, 2

Immediate Postoperative Vaccination Protocol

If vaccines were not administered at least 2 weeks preoperatively, vaccinate as soon as the patient is stable postoperatively, ideally within 14 days of surgery. 3, 1

• Administer pneumococcal vaccine (23-valent polysaccharide), which is >90% effective in healthy children 2
• Give meningococcal vaccine to prevent meningococcal sepsis 2
• Provide Haemophilus influenzae type B vaccine as part of encapsulated bacteria protection 2
• Note: The antibody response is suboptimal if given before 14 days post-splenectomy, but vaccination before discharge is preferable to missing it entirely if follow-up compliance is uncertain 3

Lifelong Antibiotic Prophylaxis

Initiate phenoxymethylpenicillin (penicillin VK) immediately postoperatively and continue indefinitely, with highest priority in the first 2 years when OPSI risk peaks. 1, 2, 4

• For penicillin-allergic patients, prescribe erythromycin as an alternative 1, 2
• Provide emergency standby antibiotics (amoxicillin) for home use at the first sign of fever >101°F (38°C), malaise, or chills 1, 4
• The risk of OPSI is 0.5-2% with mortality rates of 30-70%, and most deaths occur within the first 24 hours of symptom onset 3

Standard Postoperative Surgical Care

Maintain aggressive hydration, oxygenation, thermoregulation, and pain management to prevent vaso-occlusive complications. 3

• Continue intravenous hydration until oral intake is fully re-established 3
• Provide supplemental oxygen to maintain transcutaneous saturation >95% 3
• Avoid hypothermia using warm blankets and appropriate room temperature 3
• Implement multimodal analgesia with opioids as first-line agents for pain control 3
• Encourage early mobilization and incentive spirometry to prevent pulmonary complications 3

Critical Family Education and Safety Measures

Educate parents that OPSI can occur more than 20 years after splenectomy, making this a lifelong risk requiring permanent vigilance. 1, 2

• Instruct immediate medical attention for any fever >101°F (38°C), with blood cultures drawn before antibiotics and aggressive treatment with third-generation cephalosporins 4
• Issue a Medic-Alert bracelet or card identifying asplenic status for emergency situations 1, 4
• Provide written information about splenectomy risks and emergency protocols 2
• Notify the primary care physician of the splenectomy and vaccination history to coordinate ongoing care 4

Annual and Long-Term Vaccination Schedule

Administer annual influenza vaccination every year starting at 6 months post-splenectomy, as it reduces mortality by 54% and prevents secondary bacterial infections. 1, 4

• Use only inactivated influenza vaccine, never live attenuated (nasal spray) 1
• Plan pneumococcal reimmunization every 5-10 years using a prime-boost strategy 4
• Consider reimmunization after 2 years in young children who have reduced antibody response capacity 2

Special Infection Precautions

For animal bites, immediately administer a 5-day course of co-amoxiclav (or erythromycin if penicillin-allergic) due to increased susceptibility to Capnocytophaga canimorsus infection. 2, 4

• Provide additional prophylaxis for travel to malaria-endemic areas 3, 2
• Educate about increased risk from encapsulated bacteria: Streptococcus pneumoniae (50% of OPSI cases), Haemophilus influenzae, and Neisseria meningitidis 3, 1

Age-Specific Risk Context

Children under 5 years have infection rates >10% compared to <1% in adults, making this 5-year-old particularly vulnerable in the immediate postoperative period. 1

• The highest OPSI risk occurs in the first year post-splenectomy, especially in young children 3
• Up to one-third of infections may manifest at least 5 years after surgery, emphasizing the need for lifelong precautions 2

Common Pitfalls to Avoid

• Do not delay vaccination beyond 14 days postoperatively - the earlier after this window, the better the antibody response 3
• Do not discharge without ensuring family understands the emergency protocol - most OPSI deaths occur within 24 hours of symptom onset 3
• Do not use hypertonic fluids for hydration - these can worsen red blood cell dehydration 3
• Do not apply ice packs for pain management - hypothermia must be avoided at all costs 3