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CC May 2016 Care of Patients After Splenectomy

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echoecho's version from 2016-09-11 16:18

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Question Answer
Pts undergoing splenectomy are at increased risk of what?overwhelming postsplenectomy infection
List the etiology of postsplenectomy infection?1) encapsulated organisms like Strep pneumonia, Haemophilus influenzae type B, Neisseria meningitides 2) gram-neg infection (occasionally) 3) parasitic infestion (Babesia microti and Plasmodia falciparum) 4) animal bites (Capnocytophaga canimorsus)
What is the cause of infection in an asplenic patient?the pulmonary and hepatic macrophages are UNABLE to recognize and clear many of these organisms from the cirulation DUE to a LACK of adequate opsonization and a reduction in humoral immune response related to immunoglobulin M (IgM) antibodies and the generated endotoxins and tumor necrosis factor PRODUCES cardiovascular collapse
Though rare (annaul incidence 1 in 200 following splenectomy), OPSI (overwhelming postsplenectomy infection) is associated with a high mortality rate of what %?50%
*** The majority of OPSI cases (50-70%) occur in younger patients within the first ____ years after splenectomy, although the threat is lifelong?2
Important step in prevention of OPSI is what?immunization of the asplenic patient against causative organisms
*** List the protocol for immuniation of the asplenic patient?1) optimally, pneumococcal, H. influenza and meningococcal vaccines should be given at least 2 weeks PRIOR to elective splenectomy 2) in emergent splenectomy, give after 14th postoperative day
What yearly vaccination should asplenic patients receive?flu
Are live vaccines contraindicated in asplenic patients?no
List the vaccine recommendations for patients who were NOT immunized PRIOR to surgery?1) Pneumococcal (administer PCV 13 if NOT previously given, then administer PPSV-23 8 weeks later. If PCV 13 given previously, administer PPSV-23. Administer booster dose of PPSV-23 after 5 years) 2) Meningococcal (Administer MenACWY [Menactra, Menveo] as a 2 dose series 8-12 weeks apart if NOT previously given (age >2 years). Administer booster every 5 years. For children < 2 years of age, administer primary series approved for that age. If most recent dose was administered BEFORE age 7 years, give a booster dose 3 years later, and subsequent booster doses every 5 years. Meningococcus serogroup B vaccine (Trumemba, Bexsero) is also recommended for individuals > 10 years of age and while the vaccine is approved for ages 10-25 years, the ACIP supports use of the vaccine in older patients at risk for meningococcal infection) 3) H. influenza (administer a single dose of Hib conjugate vaccine if NOT previiously vaccinated with an age-appropriate regimen
*** Lifetime prophylaxis is a consideration for what type of patient?1) immunosuppressed patient 2) children < 16 years of age 3) adults > 50 years of age 4) patients with prior pneumoccal infection 5) those who underwent splenectomy for hemoglobinopathies or hematological malignancies 6) those with a previous episode of OPSI 7) those who demonstrated a prior inadequate immmunological response to PPSV-23
What is the recommendations for those patients in the lower risk categories (splenectomy for trauma, spherocytosis, idiopathic, thrombocytopenic purpura)?daily antibiotic prophylaxis in the immediate post-operative period and for at least 2 years
The decision to continue antibiotic prophylaxis in the lower risk group of patients requires what?a discussion with the pt on the benefits and risks of such an intervention
List the primary choices of antibiotics?1) penicillin V 2) amoxicillin (Amoxil) 3) erythromycin 4) trimethoprim-sulfamethoxazole (Bactrim) 5) levofloxacin (Levaquin) 6) moxifloxacin (Avelox)
Why is the efficacy of macrolides and Bactrim lower?due to resistance
Asplenic patient protocol regarding need to take empiric antibiotics?Amoxicillin/Clavulanate (Augmentin), Cefuroxime (Ceftin) or extended spectrum fluoroquinolones immediately when febrile AND to seek early medical care for further evaluation and treatment
Some say that self-administration of antibiotics may be delayed if the patient can do what?received medical evaluation within 2 hours
Patient should have an _______ antibiotic supply available at all times and should wear what?1) unexpired 2) medical alert jewelry
What special precautions should be taken in foreign travel?be careful of possible exposure to unusual infections, parasites and animal bites
*** In a febrile asplenic patient, if initial evaluation does NOT suggest OPSI, what may be administered and the patient observed either in-hospital or outpatient with close follow-up until complete recovery is confirmed?Ceftriaxone (Rocephin)
*** If OPSI is suspected, what should be done?prompt and aggressive in-hospital management with resuscitation, lab evaluation (blood cultures) and imaging is appropriate and empiric broad-spectrum antibiotics are indicated until the nature of OPSI is established
What may be a late complication of splenectomy, and what is it due to?1) atherosclerotic heart disease 2) related to elevated platelet count augmenting plaque formation
What patient type is at increased risk for atherosclerotic heart disease?preexisting HTN, DM, hyperlipidemia, hyperhomocysteinemia, hypercoaguable states
Is there any conclusive evidence that splenectomy increases risk of cancer?no
*** SUMMARY = What is the most significant postsplenectomy complication? What is the mortality rate of this complication1) infection (especially overwhelming postsplenectomy infection (OPSI) 2) mortality rate of 50%
*** SUMMARY = What immunizations are important parts to prevent infections in postsplenectomy?1) pneumococcal 2) meningococcal 3) Haemophilus influenza 4) influenza
*** SUMMARY = Patients should receive counseling regarding what 3 things?1) prophylatic antibiotics 2) empiric sick-day antibiotics 3) rapid evaluation for any febrile illness
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