What is the recommended protocol for a patient undergoing splenectomy?

Splenectomy Protocol

Pre-Operative Vaccination (Elective Surgery)

All patients undergoing elective splenectomy must receive comprehensive vaccination at least 2 weeks before surgery to ensure optimal antibody response. 1

Required vaccines include:

• Pneumococcal vaccines (23-valent pneumococcal vaccine is >90% effective in healthy adults under age 55) 1
• Meningococcal vaccines (including meningococcal C conjugate) 2, 1
• Haemophilus influenzae type b (Hib) vaccine for unvaccinated adults 1
• Annual influenza vaccination (inactivated only, never live attenuated) reduces mortality by 54% and prevents secondary bacterial infections 1

The 4-week pre-operative window is preferred over the 2-week minimum, as it allows for better immune response 2. For emergency splenectomy, vaccinate at least 2 weeks post-operatively once the patient stabilizes 1. If patients are discharged before 15 days post-splenectomy and the risk of missing vaccination is high, vaccinate before discharge 2.

Critical caveat: In patients who received rituximab within the previous 6 months, vaccinations may not be effective and should be readdressed once B-cell recovery has occurred 2.

Pre-Operative Testing and Evaluation

For patients with immune thrombocytopenia (ITP) undergoing splenectomy:

• Test for HCV and HIV, as these can cause secondary ITP and influence management 1, 3
• Screen for H. pylori and provide eradication therapy if positive before proceeding 1, 3
• Perform further investigations only if abnormalities exist beyond thrombocytopenia or iron deficiency 1, 3
• Bone marrow examination is not necessary in patients with typical ITP presentation 1, 3

Pre-Operative Platelet Management (ITP Patients)

• Intravenous immunoglobulin (IVIg) 1 g/kg as a one-time dose can raise platelet counts before surgery, repeated if necessary 3
• Anti-D can be considered as an alternative if corticosteroids are contraindicated 3

Perioperative Thromboprophylaxis

Mechanical prophylaxis (thigh-length pneumatic compression stockings) should be used in all patients without absolute contraindication. 2

Pharmacologic prophylaxis with low molecular weight heparin (LMWH, typically enoxaparin 40 mg daily starting 12 hours after surgery) should be administered to all patients. 2, 4

• Spleen trauma without ongoing bleeding is not an absolute contraindication to LMWH-based prophylactic anticoagulation 2
• Extended thromboprophylaxis for 2-4 weeks after discharge significantly reduces thrombosis rates (3.4% vs 10.5%) and should be provided to high-risk patients 4, 5
• Longer operative time is independently associated with portal-splenic mesenteric venous thrombosis (PSMVT), justifying extended prophylaxis in complex cases 5

Post-Operative Infection Prevention: Lifelong Antibiotic Prophylaxis

All splenectomy patients require lifelong prophylactic antibiotics, with highest priority during the first 2 years post-splenectomy when infection risk peaks. 1, 6

Standard Prophylaxis Regimen:

• Adults: Phenoxymethylpenicillin (Penicillin VK) 250-500 mg twice daily 2, 6
• Children <3 years: Phenoxymethylpenicillin 125 mg orally twice daily 6
• Children ≥3 years: Phenoxymethylpenicillin 250 mg orally twice daily 6
• Penicillin-allergic patients: Erythromycin 500 mg twice daily (adults) 2, 6

Important limitation: Phenoxymethylpenicillin does not reliably cover Haemophilus influenzae, emphasizing the critical importance of pre-operative Hib vaccination 6.

Minimum duration: 2 years in adults, 5 years in children, though lifelong prophylaxis is recommended for all patients 6. The benefit of lifelong antibiotic prophylaxis beyond 2 years is unproven and the risk of late infection is relatively low, but consensus favors continuation given the severity of overwhelming post-splenectomy infection (OPSI) 2.

Emergency Standby Antibiotics

All patients must have home antibiotics for immediate use at first sign of fever, malaise, chills, or constitutional symptoms. 2, 6

• Adults: Amoxicillin 3 g starting dose, then 1 g every 8 hours 6
• Children: Amoxicillin 50 mg/kg divided into three daily doses 6
• Alternative options include penicillin VK, erythromycin, or levofloxacin 2, 3

Patients must seek immediate emergency department evaluation even after starting antibiotics, as clinical deterioration can be rapid. 6

Management of Suspected OPSI

When infection is suspected:

• Administer intravenous benzylpenicillin 1200 mg (2 MU) over 3-4 minutes for adults and children over 10 years 6
• Third-generation cephalosporins are recommended for any post-splenectomy fever 7
• Immediate emergency department referral is mandatory 6

Patient Education and Safety Measures

Patients must be educated about lifelong infection risk, as OPSI can occur more than 20 years after splenectomy. 1, 6

Essential education includes:

• Seek immediate medical attention for fever >101°F (38°C) 2, 1, 3
• Issue Medic-Alert disc and post-splenectomy card indicating asplenic status 1, 6
• Some patients may wish to wear alert bracelets or pendants 2
• Notify primary care providers of splenectomy status and vaccination history 6

Special Circumstances

• Animal bites: Co-amoxiclav (amoxicillin-clavulanate) for 5 days due to high risk of Capnocytophaga canimorsus infection 6
• Travel to endemic areas: Additional prophylaxis for malaria, histoplasmosis, and babesiosis 6
• Malaria prophylaxis is strongly recommended for travelers 2

Age-Specific Risk Stratification

Children under 5 years have infection rates >10% compared to <1% in adults, with infants at highest risk. 1, 6

• Avoid splenectomy in children under 3-4 years if possible, as most serious infections occur in this age group 1
• Neonates have >30% risk of OPSI, justifying more aggressive and prolonged prophylaxis 6

Common Causative Organisms

The primary threats are encapsulated bacteria:

• Streptococcus pneumoniae (approximately 50% of OPSI cases) 1, 7
• Neisseria meningitidis 2, 1, 7
• Haemophilus influenzae type b 2, 1, 7

Surgical Approach Considerations

• Laparoscopic splenectomy is the standard approach for most cases, with mortality 0.2% vs 1.0% for laparotomy 2, 4
• Both laparoscopic and open approaches offer similar efficacy for medically suitable patients 3, 4
• In massive splenomegaly, hand-assisted technique should be considered to avoid conversion and reduce complications 4
• Laparoscopic splenectomy in early trauma scenarios with active bleeding is not recommended 2

Post-Operative Follow-Up for Accessory Splenic Tissue

• Imaging shows accessory splenic tissue in up to 12% of splenectomized patients 2
• In patients who relapse following initial response to splenectomy, assess for accessory spleen 2
• In patients who never responded to initial splenectomy, response to accessory spleen removal is extremely rare 2

Functional Hyposplenism

Patients with functional hyposplenism (detected by Howell-Jolly bodies and Heinz bodies on blood film) require identical preventive measures as surgical splenectomy patients 1. This occurs in sickle cell disease (HbSS, HbSC), thalassemia major, celiac disease, inflammatory bowel disease, and lymphoproliferative disorders 1. Immunize as soon as diagnosis is made 1.