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Postsplenectomy sepsis clinical features, management and prevention

Report by Ri 劉有文 /VS 韓吟宜. Postsplenectomy sepsis clinical features, management and prevention. Introduction. PSS( Postsplenectomy sepsis) Fulminant sepsis syndrome usually due to S.pneumoniae Pateint with impaired spleen function or s/p splenectomy both have risk. Role of spleen.

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Postsplenectomy sepsis clinical features, management and prevention

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  1. Report by Ri劉有文/VS韓吟宜 Postsplenectomy sepsisclinical features, management and prevention

  2. Introduction • PSS(Postsplenectomy sepsis) • Fulminant sepsis syndrome • usually due to S.pneumoniae • Pateint with impaired spleen function or s/p splenectomy both have risk

  3. Role of spleen • The largest lymphoid organ • Filter senescent, rigid RBCs • Ingesting circulating bacteria • Production of antibodies

  4. Common causes of theraputic splenectomy • Hemolytic anemia • Thrombocytopenia • Malignancy • Hypersplenism • Splenic trauma

  5. Common causes of impaired spleen function • Hemoglobinopathy • Hemolysis • Congenital asplenia • Collagen vascular diseases • Allogenic bone marrow transplantation

  6. Incidence • Children: 1/175 patient years • Adults: 1/400~500 patient years • Highest risk at first few years • 1/3 at first year • 1/2 at first 2 years • However, 1/3 after first 5 years • Can happen even 20 years after splenectomy

  7. Common pathogens • Encapsulated pathogen • Streptococcus pneumoniae(50~60 %) • No particular serotype is more common • Haemophilus influezae(20~30 %) • Neisseria spp.(10~20 %) • Other uncommon pathogens: • Capnocytophaga canimorsus • Common flora in oral cavity of dogs and cats • Bordetella holmesii

  8. Clinical manifestations • Fever • Any fever must be viewed as possible PSS • Bacteremia • Coagulopathy • Purpura, petechiae • Meningitis • Headache, neck stiffness, seizure • Respiratory symptoms • Cough, dyspnea, respiratory failure • GI symptoms • Nausea, vomiting, diarrhea, GI bleeding • Shock

  9. LAB • CBC • Blood smear • DIC profile • Lumbar puncture • CXR • Blood culture

  10. Management • Braod-spectrum antibiotics • Based on expert opinion • Must cover: • penicillin-resistant pneucoccus • beta-lactamase producing H.influenzae • General suggestion • Ceftriaxone + Vancomycin • Levofloxacin + Vancomycin • Life-support measures • H/D or CVVH for ARF • Ventilator • Inotropic agents • Fluid

  11. Prevention • Avoid unnecessary splenectomy • Immunization • Timing • 14 days before splenectomy • 14 days after splenectomy (not immediately) • Pneumococcal vaccine • PPV-23 for adults • PCPV-7 for children and some adults • Haemophilus B vaccine • Meningococcal vaccine • Re-immunization • Other vaccines: influenza vaccine

  12. Prevention • Antibiotic prophylaxis • Daily penicillin • Reduce incidence by half • Reduce mortality by 80 percents • Life-long or 3~5years? • Post PSS patients • Abx for fever • On hand • Empirical: Augmentin, Cefuroxine, fluoroquinolones • When fever, Take the drug and go to doctor without delay • Abx for dental procedures • Not recommended for no obvious advantage

  13. Summary • Be aware • Any fever may be possible PSS • Treatment in time • Empirical abx • Supportive care • Pervention • Vaccine • Daily and On hand abx

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