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Protocol / Guideline Title:

GUIDELINES FOR SPLENECTOMY IN PATIENTS WITH HEMOGLOBINOPATHIES

Department: Thalassemia Centre

Code: Med/ Thal / 016-08

Applies to:  Head Quarter  Al-Wasl  Dubai  PHC  Rashid  Other: Thalassemia Centre
Protocol Status:
 New Issue
 Part Revision
 Complete revision
Edition No.: 1
Edition Date: 17/12/2008
Revision No.:
Revision Date: 17/12/2010
1. Protocol /Guideline:

NO

YES
NO

Yes

YES

Yes
Yes

1.1 Criteria for elective splenectomy


1.1.1 - Patients on regular transfusion- Excessive transfusion requirement >200 ml/kg/year
(autoimmunity and alloimmunity should be excluded) plus any of the points in 1.1.4 or 1.1.5
below.
1.1.2 - Patients not on regular transfusion - Increasing blood transfusion requirements in
previously stable patient with stable hemoglobin levels Plus any of the points 1.1.4 or 1.1.5.
1.1.3 - Symptomatic patient dragging pain and heaviness, early satiety, breathing difficulties,
and /or physical signs such as - Massive splenomegaly >8cm below the costal margin or
spleen size increases with time.
1.1.4 - Cytopenia leucopenia or thrombocytopenia.
1.2. Symptoms and Signs:
1.2.1 - dragging pain.
1.2.2 - pressure symptoms (early satiety) and weight loss.
1.2.3 - Pain attacks suggest splenic infarction.
1.2.4 - Splenomegaly .
1.2.5 - Friction rub over the spleen.
1. 3. Investigations
1.3.1 - Abdominal sonography (splenic size, outline, hepatobiliary assessment).
1.3.2 - Full Blood count (current and previous results).
1.3.3- Coombs test (direct and indirect) and antibodies panel when appropriate.
1.4. Pre operative :
1.4.1 - Investigations (If not done within one month before surgery).
1.4.1.1 - PT, PTT.
1.4.1.2 - update virology screening (HCV, HBV, and HIV).
1.4.1.3 - LFT, renal function, glucose, electrolytes and thyroid function.
1.4.1.4 - ECG, ECHO if not done within the last 1 year in patient above 20 years.
1.4.2 - Immunization see below.
1.5. Post Splenectomy Issues:
1.5.1 - Post Splenectomy Sepsis:
1.5.1.1 - Causative Organisms
1.5.1.1.1 bacterial (Streptococcal pneumonae, Neisseria meningitides,
Hemophilous infleunzae)
1.5.1.1.2 - Protozoal (Malaria, Babesiosis)
1.5.1.2 - Clinical Picture Pneumonia, fever, primary site of infections my be absent
and death can occur within hours.
1.5.1.3 - Prognosis - Overwhelming post-splenectomy infection (OPSI) can occur in
adults as well as in children when it can be serious (50-80% fatal).
1.5.1.4 - Group at Risk of OPSI
1.5.1.4.1 - Children <5 years
1.5.1.4.2 - First two years post splenectomy (50% of infections occurred)
1.5.2 - Prevention of infection:
1.5.2.1 - Avoid elective splenectomy before 5 years of age
1.5.2.2 - Vaccination:
2

1.5.2.2.1-H-influenza type B, Polyvalent pneumococcal (pneumovax


23valent, prevenar 7 valent), meningococcal vaccine (A &C) to be
given at the same time, at different sites.
1.5.2.2.2-Timing:- At least two weeks (2 months for pneumovax)
before elective splenectomy or as soon as possible after splenectomy
1.5.2.2.3-Post bone marrow transplant patients (Refer To Post Bone
Marrow Transplation Guidelines)
1.5.2.2.4-Reimmunization: every 3-5 years for pneumococcal vaccine,
yearly influenza virus vaccine
1.5.2.3 - Prophylactic antibiotics
1.5.2.3.1 - All at risk group should receive prophylactic antibiotics for
life as penicillin V 250mg BD for adult, and penicillin V 125mg BD for
children < 5yrs of life.
1.5.2.3.2 - If allergic to penicillin, erythromycin 250 mg BD for adult,
and 125mg BD for children < 5 yrs of age.
1.5.2.3.3 - Malaria prophylaxis should be given to patient traveling to
endemic area
1.5.2.4 Patients education
1.5.2.1 - Inform patient and family about OPSI. and supply educational
material.
1.5.2.2 to report in case of fever to nearest medical authority
explaining to them that they are splenectomized
1.5.2.3 - to start broad spectrum antibiotic in case of fever and medical
help is not immediately available
1.5.2.4 - If traveling to receive immunization(N. meningitides) and
antibiotic prophylaxis (antimalarials)
1.5.2. Thrombosis prevention :
1.5.2.1 - Give prophylactic heparin preoperative if LFT and coagulation
is normal
1.5.2.2 - Give Aspirin (100 mg) post operative daily to be given
during the period of thrombocytosis (platelet > 1000, 000) and to be
continued as long as plat. Count > 1000,000.
1.5.3. Pulmonary Hypertension: see Cardiac guidelines: Management of pulmonary
hypertension.
2. Attachments:
3. References:
3.1. Up-To-Date:
http://www.uptodateonline.com/online/content/topic.do?topicKey=immuninf/5797&selecte
dTitle=2~150&source=search_result
3.2. Guidelines for the prevention and treatment of infection in patients with an absent or
dysfunctional spleen.BMJ 1996,312:430-434(17 February).
3.3. Harrison's Online - http://www.accessmedicine.com/content.aspx?aID=2875391