Asplenism in the Emergency Department

1. Asplenism in theEmergency Department Jim P. Getzinger, MD William Beaumont Hospital Royal Oak, MI

3. Splenic Trauma in the ED • Classification of injury • Contusions • Capsular tears • Hematomas – subcapsular or intraparenchymal • Lacerations • Fracture • Puncture wounds • Laceration of vessels supplying hilum • Avulsion from vascular pedicle • Classification based on time • Acute • Delayed • Occult

4. Injury Grade • GR INJURY POSITION DESCRIPTION SIZE • I Hematoma Subcapsular Nonexpanding < 10% • I Laceration Capsular tear Nonbleeding < 1cm • II Hematoma Subcapsular Nonexpanding 10-50% • II Hematoma Intraparenchymal Nonexpanding < 2 cm • II Laceration Capsular tear Bleeding w/o Trabecular involvement 1-3 cm • III Hematoma Subcapsular or Expanding Intraparenchymal • III Hematoma Subcapsular Bleeding > 50% • III Hematoma Intraparenchymal > 2 cm • III Laceration Parenchymal Involves trabecular vessels > 3 cm • IV Hematoma Intraparenchymal Ruptured and Bleeding • IV Laceration Involves hilar vessels • V Laceration Completely shattered • V Laceration Hilar region Completely devascularized

5. The Spleen Total splenectomy will be required in those with a hilar injury, massive subcapsular hematoma, fragmentation, or splenic avulsion.

6. Asplenism • Asplenic patients are at lifelong risk for serious infections, especially with encapsulated organisms such as Strep. pneumoniae, H. influenzae and N. meningitidis. • With the growing concern about antibiotic-resistant pneumococci, the appropriate detection and treatment of asplenic and hyposplenic patients has become increasingly important.

7. Post-Splenectomy Sepsis • 1930’s – Early post-surgical studies showed no increase in sepsis after splenectomy • 1952 – King & Schumacker describe 5 infants post-splenectomy for congenital spherocytosis that die of fulminant sepsis.

8. Clinical Features • Initial symptoms of overwhelming post-splenectomy infection are often mild, with an influenza-like presentation that includes fever, malaise, myalgias, headache, vomiting, diarrhea and abdominal pain. • Overwhelming Postsplenectomy infection (OPSI) first coined by Diamond in 1969 • Fulminant course • Freq. Lack of septic focus • Bacteremia, pneumonia or meningitis • Consumptive coagulopathy, adrenal hemorrhage (Waterhouse-Friderichsen syndrome) leading to shock and coma. • Large numbers of organisms in blood (>1M/ml)

9. Incidence • Problems • Rare event – Need large patient populations • Infection can be years later – long f/ups req. • Incidence varies with age, underlying disease • S/P Trauma – infection 3.3 / 100 pt-yrs • S/P Cancer – infection 16.6 / 100 pt-yrs

10. Incidence • O’Neal & McDonald 1981 • 256 Adult splenectomies f/u 45 mos • 2.7% developed sepsis • Estimated risk of death at 540 times normal population.

11. Incidence • Chaik and McCabe, 1985 • 776 splenectomies over mean 8.4 yrs • Incidence OPSI 3.7% children, 0.3% Adult • Hays et al 1986 • 234 lymphoma pts, splen. Staging, f/u 3.8 yrs • 1.7% bacteremia (83% vac / 74% abx)

12. Incidence • Ellison & Fabri, 1983 • Multistudy review of 3430 cases • Peds 4% sepsis (1.8% mortality) • Adult 1.9% sepsis (1.1% mortality) • Est. risk – 40x for sepsis & 17x for death • 20% cases in first 6mo, 60% in first 2 yrs • Overall incidence 0.9% - 6.9% • Mortality may exceed 50%

13. Risk Factors • Underlying condition • Defective cellular immunity • Hodgkins’ disease, hypogammaglobulinemia • Chemotherapy, radiation • Bone Marrow transplantation • Age Group • Children >> Adults • Children often have lower antibodies against encapsulated org. • Time after splenectomy • Greatest in first 2 yrs (50%-70%), but risk is lifelong

14. Causative Organisms • Pneumococcus - > 50% • H. influenza, Meningococcus, Strep Pyog. • Less common • Pseudomonas • Capnocytophaga canimorsus (animal bites) • Malaria • Babesiosis • Viruses – CMV, herpes, influenza

15. Mechanisms • Phagocytosis and clearance of bacteria/protozoa is impaired. • Spleen is site of production of specific antibodies • Impaired immune response • Encapsulated orgs must be opsonised before they can be phagocytosed. Production of opsonins is impaired. • Spleen controls circulating B cells capable of differentiating into antipneumococcal capsular polysaccharide antibody-secreting B cells.

17. Detection • Most patients with trauma will know • Some older patients may not recall • Hiatal hernia surgery, partial gastric resection PUD • Careful physical examination for scars • Ask about Diseases

18. Congenital Isolated congenital anomaly Congenital cyanotic heart disease Gastrointestinal Celiac disease with or without dermatitis herpetiformis* Inflammatory bowel disease (especially ulcerative colitis) Whipple’s disease Intestinal lymphangiectasia Liver disease Cirrhosis with or without portal hypertension* Chronic active hepatitis Acute alcoholism Hematologic Sickle cell disease* Other hemoglobinopathies (Hb S-C disease, Hb S-E disease, Hb S–b-thalassemia) Primary thrombocythemia Fanconi’s syndrome Malignant histiocytosis Autoimmune Vasculitis (may be associated with splenic infarct)* Systemic lupus erythematosus or discoid lupus* Rheumatoid arthritis Sjögren’s syndrome Graves’ disease Medical Conditions That May Be Associated with Hyposplenism Infiltrative Thorium dioxide administration Amyloidosis Sarcoidosis Vascular Splenic artery occlusion Splenic vein thrombosis Celiac artery thrombosis Miscellaneous HIV infection Graft-versus-host disease Bone marrow transplantation* Total parenteral nutrition High-dose steroid therapy Splenic irradiation (Hodgkin’s disease)*

19. Peripheral Blood Smear

21. Management of Patients at Risk • Vaccination • Give Pneumococcal, Meningococcal, and Haemophilus b conjugate vaccine at least 14 days before surgery (or as soon as possible) • repeat PneumoVax every 3-5 yrs depending on age & medical condition

22. Pneumococcal Vaccine • Developed 1983 • 23 serotypes (approx 90%) • Ideal conditions – fails 20-30% of recipients • Give before splenectomy if possible • Immunogenicity reduced after splenectomy or during chemo. • Age > 10 – revaccinate every 5 yrs • Age < 10 – revaccinate every 3 yrs

23. Antibiotics - Prophylaxis • Recommended for children, especially for first 2 yrs after splenectomy. • Augmentin, Bactrim, Cefuroxime • At least 5 yrs of prophylaxis • Adults – recommended standby antibiotics • Taken at first sign of infection • Still should seek medical attention • Endemic Malaria areas • Mefloquine, Doxycycline or chloroquine+proguanil

24. Studies • Do NOT delay ABX therapy for labs • Labs • Hematologic profile, lytes, creatinine, glucose • Peripheral blood smear, buffy-coat prep • Blood cultures, consider CSF cx • Chest Xray

25. Buffy-Coat

26. Empiric Antibiotic Therapy • Initial • Third Generation Cephalosporin • With or without Vancomycin • Specific Treatment based on organism • Add ciprofloxacin or gentamicin if GI/Urine source suspected • Penicillin for C. canimorsus

27. IV Drug Treatment

29. Education • Patients should be made aware of increased risk of serious infection. • Wear MedicAlert bracelet or necklace • Notify their doctor immediately of any acute febrile illness (esp. if assoc with rigors or systemic symptoms) • Seek prompt treatment even after minor dog bite or other animal bite.

30. In closing: • Consider OPSI in patients with unexplained hypotension, rapid onset, failed outpt abx. Look for scars, history!, recent travel (Babesia, malaria) • Start ABX as soon as possible. Be aggressive! • 3rd Gen. Cephalasporin With/Without Vanco • Don’t let GI symptoms divert diagnosis

31. Final Thoughts • Always check your footing/ladder carefully • Make sure someone knows you’re on the roof • If they hear a yell, and a thud, call 911. • When all else fails, hire someone to put up your holiday lights!