An audit of splenectomies in a teaching hospital in North India. Are postsplenectomy guidelines being complied with?

Abstract

Aims: Patients with an absent or dysfunctional spleen are at risk of infection by encapsulated and other bacteria. Overwhelming postsplenectomy infection (OPSI) causes most concern because it can result in significant mortality. A retrospective review of splenectomised patients in a tertiary care setting over an eight year period was carried out to determine whether current postsplenectomy guidelines were being followed. Methods: The cases were identified from the medical records and pathology files and data such as the reason for splenectomy, the preventive measures taken regarding vaccination, and antibiotic prophylaxis, together with their documentation in the discharge notes were assessed. Results: Fifty six patients were studied. Trauma, both blunt and penetrating, was the most common reason for splenectomy. Thirty six patients received pneumococcal vaccination, with 20 patients having no mention of vaccination in their case notes. The discharge notes of 50 patients mentioned their splenectomised status; however, documentation of vaccination details in the discharge summary was poor, with only three patients having the relevant information recorded. Documentation of the need for future vaccination and precautions required in the asplenic condition was also lacking. Nine patients had postsplenectomy complications, although there were no cases of OPSI. Conclusions: Adherence to standard guidelines for the management of splenectomised patients was unsatisfactory. There is a need for an improvement of the vaccination rate and careful documentation of this important health risk in the discharge summaries. Maintenance of a splenectomy registry could aid in optimising the management of these patients. The role of the spleen in the body's immune response to a variety of infections and the serious consequences of its removal have been increasingly recognised over the past 40-50 years.1 The asplenic condition results in an increased risk of life threatening sepsis as a result of encapsulated and Gram negative organisms, and carries considerable mortality. The overall incidence of septicaemia is low, but death rates from overwhelming post splenectomy infection (OPSI) have been reported to be 600 times greater than that for the general population, with an ominous estimated lifetime risk for OPSI of approximately 5%.2 With increasing awareness of the risk associated with the asplenic state, splenic salvage surgery is now gaining popularity.3 4 However, there are many clinical indications that warrant a total splenectomy, such as extensive splenic trauma or haematological disorders, resulting in a large population of asplenic patients.''Patient education and counselling at the time of splenectomy is just as important as appropriate vaccination and antibiotic prophylactic measures'' Vaccination strategies, which started with the use of the pneumococcal vaccine, have been modified since their inception in the 1970s to circumvent the emergence of antibiotic resistant strains and the recognition of other pathogens that cause...

Physicians Report Barriers to Deliver Best Practice Care for Asplenic Patients: A Cross-Sectional Survey

“…The reported findings are in correspondence with our previous study [14], where comparable vaccination- and antibiotic prescription rates were found. Internationally, publications report comparable numbers as well [9], [12], [13], [24]. Maybe the most alarming finding is that GPs as well as Surgeons fail to recommend well over one third of all asplenic patients to take antibiotics immediately in case of infection, which is the most important measure to prevent lethal infections in asplenic patients.…”

Management of post-splenectomy patients in the Netherlands

“…The asplenic state thus results in a serious impairment of clearance of mainly encapsulated bacteria, which can lead to a life-threatening infection known as post-splenectomy sepsis, PSS [5,6]. The encapsulated bacterium Streptococcus pneumoniae is the causative pathogen in 80% of cases of PSS [7,8].…”

“…In 1996, the British Committee for Standards in Haematology published Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen [14], that are considered to reflect best-practice. These recommendations were updated in 2002 [15], and consist of the following key elements: It has become clear from recent literature that post-splenectomy patients are not all being managed according to best practice [5,8,9,[16][17][18][19][20][21] The goal of our study was to determine the management of post-splenectomy patients for the first time in the Netherlands. We therefore assessed compliance with the British best practice standards by investigating (i) vaccination rates, (ii) whether or not antibiotics were prescribed and (iii) if the hospital provided the general practitioner with relevant information regarding the period after the operation.…”

Histopathological Analysis of Splenectomy Specimens in a Tertiary Care Hospital- A Two-Year Study

“…In high income countries like USA, Australia and European nations, splenectomy following traumatic injury is 15 -30%. (4,5) In Iran, Khamechian (6) reported 75% of traumatic causes and Deodhar (7) from India reported similar results. In our study, trauma accounted for 52.2% of splenectomies.…”