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- Haematological disorders:
- Hereditary spherocytosis
- Thalassaemia major
- ITP unresponsive to medical management
- Myeloproliferative disorders
- Sickle cell disease
- Traumatic injury to spleen
- Intra-operative splenic injury
- Splenic abscesses, cysts, malignancy/mass of spleen
or adjacent organ
- Non-cirrhotic portal hypertension with GI bleeding
(usually as part of a portosystemic shunt operation)
- FBC, U&E, G&H (consider Xmatch)
- Platelets may be required
- Peri-operative antibiotics - usually IV cefazolin at induction, to continue for 24hours
- Immunisations and antibiotic plan (see below)
- Laparoscopic splenectomy, where possible, is now the standard of care. Alternatively open (left subcostal incision)
- Wound infection, incisional hernia, haemorrhage, subphrenic abscess, pancreatic pseudocyst, gastric fistula/perforation
- Those with myeloproliferative disorders have higher risk of bleeding and thrombosis
- Overwhelming post splenectomy infection
Infection Risk in Splenectomised patients
The risk of post-splenectomy sepsis is greatest in the following groups:
- younger children
- early in the post-operative course (up to 2 years)
- individuals with an underlying haematologic disorder
- immune suppressed children - eg following liver transplantation
Streptococcus pneumoniae (pneumococcus) is the commonest pathogen
- No vaccines are contraindicated for splenectomised /hyposplenic patients.
- Ensure patient is up to date with routine immunisations according to National Immunisation Schedule, especially pneumococcal, Haemophilus influenzae type b (Hib) and MMR.
- Additional immunisations are recommended for asplenia/hyposplenia; commence immunisation programme as soon as condition is recognised.
- For elective splenectomy extra immunisations should be commenced as soon as possible and at least 2 weeks pre-operatively
- For emergency splenectomy commence immunisations 2 weeks post-operatively.
- The recommended schedule varies according to age and is complicated by which vaccines are funded which can vary over time. As at May 2014 the recommended schedule is as follows. Please discuss with the Paediatric Infectious Diseases or Haematology team to clarify immunisation plan. Funded vaccines shown below are accurate as at 1 July 2014 but are subject to change. Check latest pharmaceutical schedule for currently funded vaccines.
|Age at diagnosis||Vaccine (trade name)||Vaccine schedule|
|Infants aged under 12 months with functional asplenia or pre-a or post-spctomy||
|PCV13b at age 6
weeks, 3, 5 and 15 months (usual childhood Schedule), or
age-appropriate catch-up schedule:
If commencing immunisation at ages 7-11 months, give 2 doses of PCV13 at least 4 weeks apart, followed by a booster dose at age 15 months
For children aged 7-11 months who have completed the primary course with PCV10, give 1 dose of PCV13 followed by the scheduled PCV13 booster at age 15 months.
Following the completion of the PCV course, give 1 dose of 23PPV at age ≥2 years. There must be at least 8 weeks between the last PCV dose and the 23PPV dose.
Revaccinate once with 23PPV, 5 years after the 1st 23PPV.
If aged under 6 months at diagnosis, give 2 doses 8 weeks apart, with a booster at age 12 months
If aged 6-11 months at diagnosis, give 1 dose, with a further dose at age 12 months.
At age 2 years, give 2 doses of MCV4‑Dc 8 weeks apart, then a booster dose after 3 years, then 5‑yearly.
(Influvac or Fluarix)
|Annual immunisation from age 6
In the first year, give 2 doses 4 weeks apart, then 1 dose in each subsequent year.
|Children aged 12 months to under 18 years with functional asplenia or pre-aor post-splenectomy||
(Prevenar 13) and
PCV13,b,d age-appropriate catch-up schedule:
Children aged >12 monthse who have completed the
primary course of PCV10 require 1 dose of PCV13b
|If aged 12-23 months at diagnosis, give 1 dose of
MenCCV, followed by MCV4‑Dc at age 2 years, 2 doses 8
weeks apart; then a booster of MCV4-D after three years, then
If aged ≥2 years at diagnosis, give 2 doses of MCV4-Dc 8 weeks apart, and:
If the 1st MCV4-D dose was given at age <7 years, give a booster after 3 years, then 5-yearly, or
If the 1st MCV4-D dose was given at age ≥7 years, give a booster dose every 5 years.
|If aged 12-15 months, give 1 dose at age 15 months
as per the National Immunisation Schedule.
If aged 16 months to under 5 years and has not received a single Hib dose after age 12 months, give 1 dose.
If aged 5 years and older, give 1 dose, even if fully vaccinated.
|Annual immunisation. In previously unvaccinated children aged under 9 years, give 2 doses 4 weeks apart, then 1 dose in each subsequent year.|
|If no history of varicella disease or immunisation, give 2 doses at least 6 weeks apart.|
|Adults ≥18 years, pre-a or post-splenectomy||PCV13
|1 dose of PCV13.d,f|
|Give a maximum of 3 doses of 23PPV in a lifetime, a minimum of 5 years apart. The 1st 23PPV dose is given at least 8 weeks after PCV13; the 2nd a minimum of 5 years later; the 3rd dose at age ≥65 years|
|Give 2 doses of MCV4-D, 8 weeks apart, then 1 dose every 5 years.c,g|
|Give 1 dose regardless of previous vaccination history.|
|Influenza (Influvac or Fluarix)||Annual immunisation.|
|If no history of varicella disease or immunisation, give 2 doses, at least 6 weeks apart.|
a Where possible, the vaccines should be administered at least 2 weeks before elective splenectomy. For emergency splenectomy, the vaccines should be administered 2 weeks post-operatively.
b PCV13 replaces PCV10 (Synflorix) on the Schedule.
c Give MCV4-D at least 4 weeks after PCV13.
d If 23PPV has already been given (prior to any doses of PCV13), wait at least 1 year before administering PCV13.
e There are no safety concerns, regardless of the interval between the last dose of PCV10 and the 1st dose of PCV13.
f PCV13 is registered for children aged under 5 years and adults aged 50 years and older. There is emerging but limited efficacy data for PCV13 use outside of these age ranges. However, PCV13 can be used for high-risk older children and adults.
g MCV4-D is registered for individuals aged 9 months to 55 years, but there are not expected to be any safety concerns when administered to adults older than 55 years.
Some children may require long term antibiotic prophylaxis against pneumococcal infection (with amoxicillin, penicillin or erythromycin if beta lactam allergy) - please discuss with child's haematologist or the Paediatric Infectious Diseases team.
Post Operative Care and Discharge Planning
- Bloods FBC, U&E evening or next morning as per operation note
- Watch platelet count - may need anticoagulants if increases ++
- Antibiotics as per operation note (Usually IV cephazolin 24hours)
- Chest physiotherapy to prevent chest infection may be required
- Discuss medical alert bracelet (visit http://www.medicalert.co.nz/ for more info)
- Ensure vaccination plan is clearly documented on discharge letter - and clarify who will follow this through (GP or local paediatrician)
- Antibiotics: if recommended after discussion with Haematology or Paediatric Infectious Diseases:
|1||Daily oral antibiotic prophylaxis (if recommended by child's haematologist / ID team)|
|Amoxicillin||all ages||20mg/kg once daily (max 500mg)|
|OR||Penicillin VK||< 5yrs
|OR||If beta lactam allergy please discuss with Paediatric Infectious Diseases. Options include roxithromycin (if able to swallow tablets) and erythromycin.|
|2||Standby antibiotics to take if unwell and unable to access immediate medical care|
|Usually amoxicillin PO high dose (90mg/kg/day in three divided doses)|
- Discuss importance of seeking medical attention early for febrile illnesses, malaria precautions if travelling overseas, antibiotics for dog / animal bites
- Provide patient education leaflet
Information for Families
View or download a copy of the Starship Children's Health Splenectomy Leaflet
Davies J, Lewis MN, Wimperis J, Rafi I, Ladhani S, Bolton-Maggs, PHB. Review of Guideline for the Prevention of Infection in patients with an absent of dysfunctional spleen. British Journal of Haematology 2011; 155: 308 - 317.
Spelman D, Buttery J, Daley A, et Al. Guidelines for the prevention of sepsis in asplenic and hyposplenic patients. Internal Medicine Journal 2008; 38: 349 - 356.
American Academy of Pediatrics. Immunisation in special clinical circumstances: children with asplenia or functional asplenia. In Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Report of the Committee on Infectious diseases. Red Book: 2012 Report of the Committee on Infectious diseases.
Society for Surgery of the Alimentary Tract. Indications for splenectomy. Manchester (MA): Society for Surgery of the Alimentary Tract; 2000. 4 p. [5 references]
Did you find this information helpful?
- Date last published: 01 July 2014
- Document type: Clinical Guideline
- Services responsible: Paediatric Haematology/Oncology, Paediatric Infectious Diseases, Paediatric Surgery, Paediatric Gastroenterology/Hepatology
- Author(s): Helen Evans, Elizabeth Wilson, Lochie Teague, James Hamill, Tim Prestidge, Jane Skeen, Rachel Webb, Nyree Cole
- Editor: Greg Williams
- Review frequency: 2 years
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