A splenectomy can be a dangerous surgery.

Today I performed an emergency splenectomy in a 14 years old male patient following blunt abdominal trauma that culminated into a splenic rupture. What comes to my mind was the care we shall have to give to this young man now that he no longer has a spleen and I have decided to share it with you here. Let’s get started.

We include all patients who have either undergone an elective splenectomy or an emergent one. And these other patients who have a dysfunctional spleen due to celiac disease or sickle cell anaemia.

Patients with an absent or dysfunctional spleen carry an overt risk of overwhelming infection, which are fatal, though uncommon. They are due to encapsulated bacteria like Streptococcus pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis, as well as malaria, babesiosis, Capnocytophaga carnimorsus, and secondary infections following influenza.

It is therefore paramount that all patients with an absent or dysfunctional spleen are immunized according to the national immunization protocol and given appropriate antibiotic prophylaxis.

For vaccinations, patients undergoing elective splenectomy should ideally start the immunization schedule at least two weeks before surgery. For emergency splenectomy, immunization should commence at least two weeks after surgery or immediately before discharge should the latter come earlier than two weeks.

Read this article:

Let’s talk about splenic sequestration, another acute complication of sickle cell disease: Recommendations

It is very vital to check on the immunization status and history of any patient before starting immunization for that matter due to the ever-changing patterns of vaccinations in the different regions. The tables below should give you a glimpse of all the necessary immunizations following splenectomy of a dysfunctional spleen.

First diagnosed at age ten years onwards
Older children and adults, regardless of previous vaccination, should receive :
 One dose of PPV23, MenB and MenACWY conjugate vaccine followed by
 One additional dose of MenB 4 weeks later
 Annual influenza vaccine each season
First diagnosed from two years to under ten years of age
Ensure children are immunised according to the national schedule, and they should also
receive.
 One dose of PPV23, followed by
 One dose of MenACWY conjugate vaccine
 If not received the 2+1 schedule for MenB, ensure they have received two doses of
MenB 8 weeks apart since their first birthday
 If they have not received any PCV previously they should receive a dose of PCV13
followed by a dose of PPV23 8 weeks later
 Annual influenza vaccine each season
First diagnosed at 12-23 months of age
If not yet administered, give the routine 12-month vaccines: Hib/MenC, PCV13, MMR and
MenB, plus
 One additional booster dose of PCV13 and one dose of MenACWY conjugate
vaccine 8 weeks after the 12-month vaccinations; and
 One dose of PPV23 after the second birthday and at least 8 weeks after the last
dose of PCV13
 Annual influenza vaccine each season
First diagnosed under 1 year of age
Children should be fully immunised according to the national schedule, and should also
receive
 Two doses of MenACWY vaccine at least 4 weeks apart during their first year
 An additional priming dose of PCV13, such as to receive a total of 2 priming doses
at least 8 weeks apart (commencing no earlier than 6 weeks of age) in their first
year
 One additional booster dose of PCV13 and one dose of MenACWY conjugate
vaccine 8 weeks after the 12-month vaccinations; and
 One dose of PPV23 after the second birthday and at least 8 weeks after the last
dose of PCV13
 Annual influenza vaccine each season for patients aged over 6 months
Revaccination Schedule
 Offer annual influenza vaccine to all patients
 PPV23 vaccination every 5 years

Offer lifelong antibiotic prophylaxis to all patients with an absent or dysfunctional spleen due to the increased risk of infections in this category of patients. It is greatest immediately after splenectomy due to pneumococcal infections.

Patients with the following risk factors are at the highest risk of infections. -Age below 16 and over 50 years 

-inadequate serological response to pneumococcal vaccination

– history of previous intensive pneumococcal disease

– splenectomy due to haematological malignancy 

– an active, ongoing graft-versus-host disease.

 The tables below will shed some light on the nature of antibiotic prophylaxis needed by this group of patients.

 ProphylaxisDuration
First linePenicillin V 250mg bdMinimum 2 years but preferably lifelong. We can, however, discontinue antibiotic prophylaxis in those above 5 years of age with sickle cell anaemia who received PCV and those that do not have a history of severe pneumococcal infection.
If penicillin allergyClarithromycin 250mg bd

 ProphylaxisDuration
First lineUnder 1 year Penicillin V 62.5mg bd
1 - 5 years Penicillin V 125mg bd
5 - 18 years Penicillin 250mg bd
Give amoxicillin instead of penicillin if there's need to cover for H. influenzae.
Continue antibiotic prophylaxis until at least 16 years old and a minimum of 2 years and preferably lifelong.
But, you can discontinue antibiotic prophylaxis in children over 5 years of age with sickle cell anaemia who have received PCV and those that do not a history of severe pneumococcal infection.
If penicillin allergy1 month - 2 years Erythromycin 125mg bd
2 - 8 years Erythromycin 250mg bd
8 - 18 years Erythromycin 500mg bd

Patients must have some antibiotics at home since the infections breakthrough despite all these measures. They should have an education on the importance of seeking urgent medical help should any complications occur.

For patients living in malaria-endemic regions, malaria prophylaxis is paramount. It is crucial to know what your local guidelines recommend. 

Visit UpToDate for more information. You can as well download this article and get well acquainted with the matter at hand. Share your comments below.

By IAmDrSsekandi

I am a medical officer interested in maternal and child health. I am a content creator, author and founder of https://ssekandima.com. I do private practice with a public touch. I am a certified digital marketer. I earned certificates in Understanding Clinical Research and Writing in Sciences from the University of Cape Town and Stanford University respectively.

Leave a Reply