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Protocol / Guideline Title:


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:






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
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). - PT, PTT. - update virology screening (HCV, HBV, and HIV). - LFT, renal function, glucose, electrolytes and thyroid function. - 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: - Causative Organisms bacterial (Streptococcal pneumonae, Neisseria meningitides,
Hemophilous infleunzae) - Protozoal (Malaria, Babesiosis) - Clinical Picture Pneumonia, fever, primary site of infections my be absent
and death can occur within hours. - Prognosis - Overwhelming post-splenectomy infection (OPSI) can occur in
adults as well as in children when it can be serious (50-80% fatal). - Group at Risk of OPSI - Children <5 years - First two years post splenectomy (50% of infections occurred)
1.5.2 - Prevention of infection: - Avoid elective splenectomy before 5 years of age - Vaccination:
2 type B, Polyvalent pneumococcal (pneumovax

23valent, prevenar 7 valent), meningococcal vaccine (A &C) to be
given at the same time, at different sites. At least two weeks (2 months for pneumovax)
before elective splenectomy or as soon as possible after splenectomy bone marrow transplant patients (Refer To Post Bone
Marrow Transplation Guidelines) every 3-5 years for pneumococcal vaccine,
yearly influenza virus vaccine - Prophylactic antibiotics - 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. - If allergic to penicillin, erythromycin 250 mg BD for adult,
and 125mg BD for children < 5 yrs of age. - Malaria prophylaxis should be given to patient traveling to
endemic area Patients education - Inform patient and family about OPSI. and supply educational
material. to report in case of fever to nearest medical authority
explaining to them that they are splenectomized - to start broad spectrum antibiotic in case of fever and medical
help is not immediately available - If traveling to receive immunization(N. meningitides) and
antibiotic prophylaxis (antimalarials)
1.5.2. Thrombosis prevention : - Give prophylactic heparin preoperative if LFT and coagulation
is normal - 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
2. Attachments:
3. References:
3.1. Up-To-Date:
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