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Part IV
https://t.me/med1917
Protocols of Special Relevance
Chapter 15
https://t.me/med1917
Immunization Routines forSurgical
Splenectomy
MichelleLippincott andVicVelanovich
Splenic Anatomy andFunction
The spleen is the largest secondary lymphoid organ in the body and is unique in
structure and function. It is the only portion of the lymphatic system with a direct
blood supply. This feature allows it to lter non-functional or damaged blood cells
and opsonized particulates. Furthermore, by facilitating otherwise low-probability
interactions between antigen-presenting cells (APCs) and cognate lymphocytes, it
serves as a bridge between the adaptive and innate immune response [1].
The splenic parenchyma consists of three distinct functional “zones.” These are
termed the white pulp, red pulp, and marginal zone (also the perifollicular zone).
The red pulp makes up the majority of the splenic parenchyma. It consists of a system of cords that lack endothelium and allow for direct interaction of red pulp macrophages with the contents of the blood [2]. These macrophages serve to remove
damaged or opsonized cells or pathogens [1, 3]. The white pulp is the primary site
of adaptive immune response in the spleen. It is analogous to lymph nodes containing distinct T and B cell zones. The white pulp’s adaptive response results from
interactions between antigen-presenting cells and B or T lymphocytes [2–4]. This
interaction produces highly specic antibodies against encountered pathogens for
adaptive immunity [3]. The marginal zone abuts the white pulp and contains marginal zone B cells. These act as the primary response against bloodborne pathogens.
These B cells form IgM antibodies that promote T-cell responses [3]. Marginal zone
location of memory B cells that produce IgM, which is critical for the opsonization
of encapsulated bacteria [4].
M. Lippincott · V. Velanovich (*)
Department of Surgery, Morsani College of Medicine, The University of South Florida,
Tampa, FL, USA
e-mail: mlippincott@usf.edu; vvelanov@usf.edu
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_15
247© The Author(s), under exclusive license to Springer Nature
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M. Lippincott and V. Velanovich
Overwhelming Post-splenectomy Infection
Increased risk of infection is a well-known complication of splenectomy [5–7].
Overwhelming post-splenectomy infection (OPSI) describes fulminant sepsis
unique to asplenic patients. Without opsonization, infection with encapsulated
organisms can quickly progress to life-threatening sepsis. Notably, Streptococcus
pneumoniae causes 50–90% [6, 8] of these infections, followed by Haemophilus
inuenzae and Neisseria meningitidis [4, 5]. Other implicated organisms with
higher disease risk in asplenic patients include Plasmodium falciparum, Babesia
microti, and Capnocytophaga canimorsus [8]. Asplenic patients also have an
increased risk of infection from non-encapsulated organisms [5].
The incidence of invasive infection in patients undergoing splenectomy for all
indications is 3.2% [5]. Although the incidence is low, the mortality rate is 50–70%
[7], with death resulting from septic shock, multisystem organ failure, disseminated
intravascular coagulation, and adrenal hemorrhage.
The concern about OPSI leads to various techniques for splenic salvage in hopes
of preserving splenic function. It is not the purpose of this chapter to review such
techniques, but these include operative splenic salvage, partial splenectomy, and
selective splenic artery branch embolization [9]. Nevertheless, despite these efforts,
splenectomy for trauma and disease may be unavoidable.
One of the potential consequences of splenic trauma, with or without splenectomy, is splenosis. Splenosis occurs with fragments of the injured implant onto various surfaces of the peritoneal cavity, with the most likely location being the omentum
[10]. Although splenosis at one time was thought to provide some immune function,
this function is not sufcient to provide a reliable method to prevent OPSI [10].
Therefore, the presence of splenosis, or accessory spleens for that matter, should not
be the reason to avoid post-splenectomy immunizations.
The data regarding OPSI is limited by the wide variety of indications for splenectomy and the need for subgroup analysis. We know that the incidence of postsplenectomy sepsis is similar in adults and children, though the mortality is higher
in children [5]. Adult patients who undergo splenectomy for non-traumatic causes
carry a higher risk of infection than their traumatic counterparts; this includes infections with non-encapsulated organisms [11]. In both adults and children, infection
rates are highest in patients undergoing splenectomy for thalassemia major and
sickle cell anemia [5]. The timing of OPSI after splenectomy is not well agreed
upon though the quoted overall mean time to the onset of infection was 22.6months
for all causes of splenectomy [5].
The mainstay of treatment of post-splenectomy sepsis involves early identication and treatment with empiric broad-spectrum antibiotics. Early identication and
treatment may reduce mortality by 10% [12].
Lastly, although OPSI is the most feared of post-splenectomy complications,
other infectious adverse outcomes also occur. These include intra-abdominal
abscesses, pneumonia, surgical site infections, as well as others [13]. These infections tend to occur in the peri-operative period, whereas OPSI tends to occur months
or years after splenectomy.
15 Immunization Routines forSurgical Splenectomy
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Immunization Recommendation forAsplenic or
Hyposplenic Patients
Indications andTiming
Post-splenectomy vaccines are mandated in all patients undergoing splenectomy for
any indication. Immunizations are not recommended in patients who have undergone angioembolization as these patients have preserved splenic immune function
[14]. For the purpose of this book, guidelines for vaccinations are limited to adults.
In cases of elective splenectomy, the initial dose of vaccines should be given at
least 14days before surgery, and in some cases, are recommended 4–6weeks preoperatively [15]. In cases of unplanned splenectomy, they should be given immediately post-operatively once the patient’s condition is stable [16].
Pneumococcal Pneumoniae
The United States Centers for Disease Control (CDC) recommendations for vaccination of anatomically or functional asplenic adults are as follows [16]:
– PCV13 vaccine either pre-operatively or immediately post-op
– PPSV23 8weeks after PCV 13
– PPSV23 5years following the rst dose of PPSV23
Neisseria Meningitidis
CDC recommendations for Neisseria meningitidis vaccination in asplenic patients
consist of recommendations for ACWY serotypes and B serotypes as listed
below [16]:
Meningococcal Serotypes—ACWY:
– 2 dose series of either MenAWCY vaccine 8weeks apart [MenACWY-CRM
(Menevo) OR MenACWY-D (Menactra)]
– Repeat in 5years if last dose was at age >7, 3years if last dose at age <7
– Of note, MenACWY-D should not be given concomitantly with PCV13 but
instead 4 weeks afterward as this can attenuate antibody response to PCV13.
MenAVWY-CRM can be given concomitantly with PCV13.
Meningococcal B:
– Two-dose series of MenB-4C (Bexsero), 1month apart OR
– Three-dose series of MenB-FHbp (Trumenba) with dose 2 at 1–2 months and
dose 3 at 6months
– Either can be given concomitantly with Men-ACWY
– There are no recommendations for boosters for MenB
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Hemophaelous Inuenzae
– One-time dose of Haemophilus inuenzae type B conjugate vaccine [16].
Inuenza
– Administer seasonal inuenza vaccine to asplenic patients to mitigate the risk of
secondary pneumonia [15].
– Asplenic patients should not receive live attenuated vaccines.
M. Lippincott and V. Velanovich
Challenges withImmunizations
As one can see by the schedule provided above, obtaining the appropriate vaccinations can be a daunting task and requires 7–9 vaccinations within the rst 12months
post-splenectomy. The studied booster compliance rate is poor [17–19]. Suggested
interventions to improve compliance include patient education and surgeon ownership of the vaccine schedule [15].
Prophylactic Antibiotics
In addition to immunizations, the asplenic patient, as well as their family members,
need to be appraised of the early signs and symptoms of OPSI. This is vital as OPSI
is a rapidly progressing disease, and the time period from rst symptoms to death
can be short, measured in hours to a few days. Therefore, the American Society of
Hematology recommends prophylactic antibiotics, depending on age, time since
splenectomy, degree of immunocompromise, or prior episodes of sepsis for adults
of penicillin VK 250mg orally twice a day (or cephalexin 250mg orally twice a day
for patients with penicillin allergies). For patients with early signs of sepsis (e.g.,
fever), emergency antibiotic administration prior to arrival to an emergency department of amoxicillin-clavulanate 875/125 mg orally twice a day [20]. Therefore,
asplenic patients should have such antibiotics on hand for immediate use if symptoms of infections occur.
Conclusions
Vaccinations in splenectomized patients are of the utmost importance in preventing
life-threatening infections. Although well dened, the current guidelines for vaccination can be confusing for patients and providers. Furthermore, the logistical
15 Immunization Routines forSurgical Splenectomy
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challenge of providing these vaccines can lead to poor compliance and suboptimal
benet regarding infection prevention. This challenge highlights the importance of
surgeon involvement in maintaining up-to-date knowledge of these vaccine schedules and identifying barriers to obtaining such immunizations.
References
1. Lewis SM, Williams A, Eisenbarth SC.Structure and function of the immune system in the
spleen. Sci Immunol. 2019;4 https://doi.org/10.1126/sciimmunol.aau6085.
2. Mebius RE, Kraal G.Structure and function of the spleen. Nat Rev Immunol. 2005;5:606–16.
https://doi.org/10.1038/nri1669.
3. Kuchar E, Miśkiewicz K, Karlikowska M.A review of guidance on immunization in persons
with defective or decient splenic function. Brit J Haematol. 2015;171:683–94. https://doi.
org/10.1111/bjh.13660.
4. Sabatino AD, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet.
2011;378:86–97.
5. Bisharat N, Omari H, Lavi I, Raz R.Risk of infection and death among post-splenectomy
patients. J Infection. 2001;43:182–6. https://doi.org/10.1053/jinf.2001.0904.
6. Spelman D, Buttery J, Daley A, etal. Guidelines for the prevention of sepsis in asplenic and
hyposplenic patients. Intern Med J. 2008;38:349–56.
.2007.01579.x.
7. Holdsworth RJ, Cuschieri A, Irving AD.Postsplenectomy sepsis and its mortality rate: actual
versus perceived risks. Br J Surg. 1991;78:1031–8. https://doi.org/10.1002/bjs.1800780904.
8. Sinwar PD.Overwhelming post splenectomy infection syndrome—review study. Int J Surg.
2014;12:1314–6. https://doi.org/10.1016/j.ijsu.2014.11.005.
9. Coccolini F, Montori G, Catena F, etal. Splenic trauma: WSES classication and guidelines
for adult and pediatric patients. World J Emerg Surg. 2017;12:40. https://doi.org/10.1186/
s13017- 017- 0151- 4.
10. Connell NT, Brunner AM, Kerr CA, Schiffman FJ. Splenosis and sepsis: the bornagain spleen provides poor protection. Virulence. 2011;2:4–11. https://doi.org/10.4161/
viru.2.1.14611.
11. Camejo L, Nandeesha N, Phan K, etal. Infectious outcomes after splenectomy for trauma,
splenectomy for disease and splenectomy with distal pancreatectomy. Langenbecks Arch
Surg. 2022;407:1685–91.
12. Brigden M, Pattullo AL. Prevention and management of overwhelming postsplenectomy
infection—an update. Crit Care Med. 1999;27:836–42.
13. Vagholkar DK. Complications of splenectomy. Int J Surg Sci. 2020;4:218–22. https://doi.
org/10.33545/surgery.2020.v4.i2d.420.
14. Freeman JJ, Yorkgitis BK, Haines K, etal. Vaccination after spleen embolization: a practice management guideline from the Eastern Association for the Surgery of Trauma. Injury.
2022;53:3569–74. https://doi.org/10.1016/j.injury.2022.08.006.
15. Casciani F, Trudeau MT, Vollmer CM. Perioperative immunization for splenectomy and
the surgeon’s responsibility. JAMA Surg. 2020;155:1068–77. https://doi.org/10.1001/
jamasurg.2020.1463.
16. Kroger A, Bahta L, Long S, Sanchez P. Advisory Committee on Immunization Practices
(ACIP) general best guidance for immunization; 2023. https://www.cdc.gov/vaccines/hcp/
acip- recs/general- recs/downloads/general- recs.pdf. Accessed 29 March 2023.
17. Gonzalez RA, Robbins JM, Garwe T, et al. Effect of post-splenectomy booster vaccine program on vaccination compliance in trauma patients. Am Surg. 2021;87:796–804. https://doi.
org/10.1177/0003134820956274.
https://doi.org/10.1016/s0140- 6736(10)61493- 6.
https://doi.org/10.1111/j.1445- 5994
https://doi.org/10.1007/s00423- 022- 02446- 3.
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18. Alvarado AR, Udobi K, Berry S, et al. An opportunity for improvement in trauma care:
8-week booster vaccination adherence among patients after trauma splenectomy. Surgery.
2018;163:415–8. https://doi.org/10.1016/j.surg.2017.09.037.
19. Bianchi FP, Stefanizzi P, Spinelli G, etal. Immunization coverage among asplenic patients and
strategies to increase vaccination compliance: a systematic review and meta-analysis. Expert
Rev Vaccines. 2021;20:297–308. https://doi.org/10.1080/14760584.2021.1886085.
20. Lee GM. Preventing infections in children and adults with asplenia. Hematology.
2020;2020:328–35. https://doi.org/10.1182/hematology.2020000117.
M. Lippincott and V. Velanovich
Chapter 16
https://t.me/med1917
Management oftheDifculty Airway
inthePerioperative Period (A Surgical
Perspective)
R.H.Kelley, D.C.Sullivan, andJ.A.Scott
Introduction
Complications associated with airway management are the leading cause of death
or permanent brain damage in otherwise healthy patients who undergo anesthesia
for elective procedures [1]. A one-year review of major airway complications at
National Health Services Hospitals, UK (NAP4) found 46 events per million general anesthetics, with an associated mortality of 5.6 per million. Difcult or delayed
intubation, failed intubation and a catastrophic scenario now referred to as “can’t
intubate can’t oxygenate” accounted for an estimated 39% of events [2].
There is evidence that repeated conventional tracheal intubation attempts contributes to patient morbidity. A practice analysis of emergent intubations showed that
beyond two intubation attempts there is an increase in hypoxemia, esophageal intubation, regurgitation, aspiration, bradycardia, airway trauma and cardiac arrest [3].
Airway complications can result in adverse outcomes including brain injury, cardiopulmonary arrest, airway trauma, need for emergency surgical airway access and
unanticipated ICU stay [3–5]. Data from the United States published in 2009 shows
mortality rate of 1.1 per million for patients undergoing anesthesia, with 2.3% of
deaths attributed to failed or difcult intubation [6]. Respiratory complications that
occur during emergency airway management are estimated to account for one third
of all anesthetic deaths [3].
R. H. Kelley
Department of Anesthesiology & Perioperative Medicine, UMass Chan Medical School,
Worcester, MA, USA
e-mail: Rosemary.Kelley@umassmed.edu
D. C. Sullivan · J. A. Scott (
Division of Critical Care, Department of Anesthesiology & Perioperative Medicine, UMass
Chan Medical School, Worcester, MA, USA
e-mail: Daniel.Sullivan@umassmemorial.org; aaron.scott@umassmemorial.org
Switzerland AG 2024
J. Faintuch, S. Faintuch (eds.), Recent Strategies in High Risk Surgery,
https://doi.org/10.1007/978-3-031-56270-9_16
*)
253© The Author(s), under exclusive license to Springer Nature
254
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In otherwise healthy patients, difculty with airway management leading to a
severe outcome occurs with a frequency of 11.6 per million [1]. According to 2019
claims analysis, in recent years difcult tracheal intubations tended to occur in
sicker patients, with 76% of difcult intubations between 2000 and 2012 involving
ASA III-V categories [5].
R. H. Kelley et al.
Difcult Airway
It corresponds to anticipated or unanticipated barriers or failure by a trained anesthesia provider in any of the following areas: face mask ventilation, laryngoscopy,
ventilation with supraglottic airway, tracheal intubation, extubation or invasive
airway [4].
While the overall incidence of difcult airways is estimated to be low (1.4–5.0%
[7, 8]), there is signicant mortality. Impossible face mask ventilation occurs at an
estimated rate of 0.07–0.16% [9]. Difcult intubation occurs at a rate of 1.6 per
1000 with the incidence of failed intubation being 1.3 per 10,000 [1]. Any of these
scenarios can lead to a “cannot intubate, cannot oxygenate” scenario, which occurs
in less than 1 out every 5000 elective cases. This requires a surgical airway rescue
in less than 1 out of every 50,000 cases, nevertheless accounts for 25% of anesthesiarelated deaths [10]. Delays in surgical airway initiation during these emergencies
remains an issue.
Increased Serious Complications
A 2019 claims analysis revealed that despite similar incidence of difcult intubations, incidence of brain damage or death at induction of anesthesia was 5.5 times
higher between 2000 and 2012 when compared to 1993–1990 [5]. Two-thirds of difcult intubations occur at induction in the operating room, 13–14% occur during the
procedure, 14–16% at extubation and 4–7% occur during recovery in the postanesthesia care unit [5]. Failure to predict and plan for a patient with a difcult airway remains the most important factor contributing to catastrophic events [2, 4, 5, 10].
Airway Assessment
Risk assessment for predicting challenging airways has been a signicant topic of
research in anesthesiology. Despite this, anticipation of difcult airways remains
incredibly difcult. A 2015 cohort study involving 188,064 patients had 3391
16 Management of the Difculty Airway in the Perioperative Period (A Surgical…
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difcult tracheal intubations and 857 cases of difcult mask ventilation [11].
Notably 93% of the difcult tracheal intubations were unanticipated. Difcult mask
ventilation was unanticipated in 94% of cases. According to a 2018 Cochrane
Review with 844,206 participants, there is no current bedside screening test alone
or in combination, that is entirely reliable in detecting an unanticipated difcult
airway [12].
History
A thorough history and physical examination is vital emphasizing prior diseases
and episodes of difcult intubation, neck surgery or injury, snoring or related medical conditions including obstructive sleep apnea (OSA). A history of difcult intubations is the most predictive risk factor [10].
Facial Features andAnatomical Measures
The “3-3-2 Rule” can be applied for mouth and neck anatomical evaluation (see
Table16.1). Additional criteria include head and neck mobility, neck circumference, presence of a beard (indicator of difcult face mask ventilation), and ability to
prognath (the upper lip bite test).
The upper lip bite test is the best pre-operative indicator of difcult airway. The
inability to project forward the lower jaw, and thus bite any part of the upper lip with
the lower incisors, has 60% sensitivity for detection of difculty in tracheal intubation [10]. Conversely, the ability to extend teeth above the lower border of the upper
lip is predictive of a reduced risk intubation. These tests are less predictive in cases
with edentulism.
Indices for difcult airway evaluation include neck circumference to thyromental distance, height to thyromental distance, and thyromental to hyomental distance ratios.
Table 16.1 Visual representation of the important features distinguishing possible easy versus
difcult airway with the 3-3-2 Rule for Difcult Airway Evaluation. Created by Dr. Sullivan
The “3–3-2 Rule” for Difcult Airway Evaluation
Interincisor distance (mouth opening) ≥3 ngerbreadths <3 ngerbreadths
Hyoid-mental distance ≥3 ngerbreadths <3 ngerbreadths
Hyoid-thyroid cartilage distance ≥2 ngerbreadths <2 ngerbreadths
Easy Difcult
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