6.7 ITP + Splenectomy

Question 1

A 35-year-old woman presents for splenectomy for idiopathic/immune thrombocytopenic purpura, which
is not controlled with medical management.

a) Which vaccinations should this patient receive (3 marks) and when should they be given? (2 marks)

Answer 1

Initial vaccinations at least two (ideally four to six) weeks preoperatively, or two weeks afterwards:

> > Haemophilus influenza b.
Pneumococcus (booster dose every five years).
Meningitis B and C.

Annually:
» Influenza.

Question 2

b) List three immunological functions of the spleen in the adult. (3 marks)

Answer 2

> > Synthesis of antibodies and immune proteins
that facilitate phagocytosis.

> > Removal from circulation of
antibody-coated blood cells and bacteria.

> > Reservoir of monocytes
that can specialise into dendritic cells and
macrophages.

Question 3

c) What are the preoperative considerations related to this patient’s condition? (8 marks)

Answer 3

Splenectomy is undertaken to stop the splenic destruction of platelets. It is indicated if there is insufficient or non-sustained improvement with
steroid treatment. The patient may therefore have a very low platelet count preoperatively, and immunoglobulin infusions may be utilised to give a
temporary boost. If the platelet count is critically low, there is a risk of spontaneous and catastrophic bleeding, and platelet transfusions may be
required.

Airway:
» Risk of swollen soft tissues and tongue
due to multiple haematomas with
critically low platelet count.

> > Difficult airway must be anticipated –
plan for airway management
involving minimal trauma.

Cardiovascular:
>> Aim for minimal surges in blood pressure as bleeding may be precipitated –
optimise pain relief, 
consider use of remifentanil infusion
 and obtund  response to laryngoscopy.

Neurological:
» Pain control plan:
neuraxial techniques contraindicated
in the presence of low platelet count.

Nonsteroidal anti-inflammatory drugs
should be avoided.

> > Avoidance of surges in blood pressure and straining on tube (use of muscle relaxant or remifentanil) – critically low platelet count renders
patient at risk of catastrophic intracerebral bleeding.

Endocrine:
» Consider need for perioperative steroid supplementation if the patient has had
recent high-dose treatment.

Gastrointestinal:
» Assess for possibility of gastrointestinal haemorrhage.

Consideration of need for rapid sequence
induction if stomach is therefore ‘full’.

Haematological:
» Platelet transfusion may be
required if platelet count very low
– liaise with haematologist.

> > Cross-matched blood must be
available due to possibility of major
haemorrhage:

atypical antibodies may be present
due to past blood transfusions.

Immunological, infective:

> > Discuss with the haematologist the need for postoperative antibiotic prophylaxis.

Cutaneomusculoskeletal:
» Consider need for padding and care with handling due to risk of bruising
and bleeding secondary to low platelet count.

Question 4

d) Describe the rationale for (1 mark) and principles of (3 marks) conservative management for traumatic
splenic rupture.

Answer 4

Rationale:
» Avoidance of major surgery with its attendant risks.
» Retention of splenic immunological function.

Principles – patient selection based on:

> > Haemodynamic stability.

> > Grading of splenic injury on CT scanning,
lower grades being more
amenable to conservative management.

> > Local availability of radiological interventions
for angioembolisation if necessary.

> > Absence of need for laparotomy for any other indication.