Post-splenectomy state

Which of the following are potential complications of splenectomy:

a
Gallstones
b
Hemolysis
c
Infection
d
Thrombosis
e
Hematuria

In this section we will discuss 2 important complications of splenectomy:

  • Infection
  • Thrombosis

Infectious risk

Asplenia and hyposplenism are major risk factors for overwhelming sepsis (more than 50-times higher than in the general population; lifetime risk 1% to 2%), especially with encapsulated organisms such as:

  • S. pneumoniae (50–90% of cases)
  • N. meningitidis
  • H. influenzae type b

(Additionally, splenectomized patients are at increased risk of severe zoonotic diseases caused by Babesia, Bordetella, and Capnocytophaga species, occurring after tick, cat, and dog bites, respectively).

Fever in a patient with splenectomy:

  • Is a medical emergency.
  • Requires prompt treatment with empirical antibiotics.

Asplenic sepsis has a mortality rate of 50–70%.

The risk of sepsis is highest in the first 2 years following surgery, but remains elevated lifelong.

Given the seriousness of this complication, what steps would you like to take in our patient:

a
Educate him about the risk
Provide instructions on what to be on the lookout for and the importance of seeking emergent medical care in the event of an acute febrile illness.
b
Antibiotic prophylaxis
Daily penicillin may be considered for asplenic children < 5 years old, 1-2 years postsplenectomy for patients ≥ 5 years old, and life-long for patients with an episode of sepsis. Prophylaxis prior to invasive procedures is controversial.
c
Leukocyte transfusions
d
Vaccine prophylaxis
Patients with asplenia should be vaccinated against Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis, as well as receive an annual influenza vaccination.

Vaccinations for splenectomized patients

All vaccines should be given ≥ 2 weeks prior to splenectomy if possible or 2 weeks post splenectomy.

Adults who are undergoing splenectomy or who have functional or anatomic asplenia or hyposplenism should receive vaccinations against S. pneumoniae (pneumococcus), H. influenzae type b, and N. meningitidis (meningococcus):

  • Pneumococcal vaccination
    • Two types of pneumococcal vaccination are recommended:
      • PCV13 (Prevnar)
      • PPSV23 (Pneumovax)
    • These two vaccines are given as a primary series, followed by revaccination (booster) with PPSV23:
      • Single dose of PCV13 followed by PPSV23 ≥8 weeks later
      • Boost with PPSV23 every five to seven years thereafter
    • Some patients may have received partial vaccination in the past:
      • For adults who have previously received a dose of PCV13 (but not PPSV23), give a single dose of PPSV23 ≥8 weeks after the PCV13 dose
      • For adults who have previously received PPSV23 (but not PCV13), give a single PCV13 dose ≥1 year after the most recent PPSV23 dose.
      • For adults who have previously received both PCV13 and PPSV23, revaccinate with PPSV23 five to seven years after the last PPSV2.
  • H. influenzae type b vaccination (Hib)
    • A single dose of Hib vaccine is recommended prior to splenectomy or for patients with asplenia or hyposplenism.
    • If the patient doesn’t know whether they have been vaccinated in past, give a single dose.
    • Revaccination is not needed for Hib (no booster).
  • Meningococcal vaccination 
    • Two types of meningococcal vaccinations recommended:
      • Quadrivalent meningococcal conjugate vaccine that protects against meningococcal serotypes A, C, W, and Y  (MenACWY; Menactra, Menveo, MenQuadfi)
      • Univalent serogroup B vaccine (MenB-4C [Bexsero] or MenB-FHbp [Trumenba])
    • Both vaccines are given as a primary series:
      • Give two doses of a MenACWY vaccine ≥8 weeks apart, booster every five years.
      • Meningococcus serogroup B (MenB), either with Bexsero (two doses spaced at least one month apart) or Trumenba (three doses at 0, 1 to 2, and 6 months); booster 1 year after completion of primary series and every 2 to 3 years thereafter.

All splenectomized patients should receive influenza vaccine yearly.

In our case, the patient had received all vaccinations. What vaccines will he need boosters for as you follow him into the future?

a
PC13
b
PPSV23
Every five to seven years
c
Hib (Haemophilus influenzae type b)
d
Meningococcal ACWY (MenACWY)
Every five years
e
Meningococcal B (MenB)
Booster 1 year after completion of primary series and every 2 to 3 years thereafter.

Thrombotic risk

Splenectomy has also been shown to be a risk factor for thromboembolic events such as portal vein thrombosis, deep vein thrombosis, and pulmonary embolism.

The mechanism of thrombophilia is not well understood but may be associated with the role of the spleen in clearing microparticles from the circulation as well as increased platelet counts following splenectomy.

There is currently no guidance regarding thromboprophylaxis in these patients. Grace et al recommend the following:

  • Prophylactic anticoagulation can be considered, once safe from a bleeding perspective, immediately post-splenectomy, in those with other thrombotic risk factors.
  • Low dose aspirin could be considered until the platelet count is <500 x 109/L in adults with advanced age, a history of thrombosis, hypercholesterolemia and cigarette smoking.