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Welcome, Dr. Sutton! (was RE: splenectomy and vaccination)

Pret Bjorn p.bjorn at tds.net
Thu Nov 25 15:57:02 GMT 2010


I have to say how great to see you on the List, Dr. Sutton.  Seems like most
of trauma's Pantheon is accessible here with a quick email.  Dr. Brohi has
certainly created one of the deepest and broadest repositories of trauma
experience anywhere, ever.  

What a privilege it is to share bandwidth with the lot of you.

Pret Bjorn, RN
Bangor, ME USA


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Sutton, John E.
Sent: Thursday, November 25, 2010 9:38 AM
To: Trauma-List [TRAUMA.ORG]
Subject: RE: splenectomy and vaccination

My experiences with post splenectomy infections in my pre "retirement" days
at Dartmouth:

23 yo nurse who had refractory ITP. She was vaccinated one month prior to
surgery, underwent splenectomy, and one month post op presented to the ED
with 12 hx  of URI symptoms and fever to 101. She had taken an oral dose of
penicillin at home as instructed for temp elevation. Arrived comatose and
hypotensive. Pneumococcus was seen on gram stain from the spun down buffy
coat of her blood. ICU stay ~ 7 days, aggressive resuscitation, fluid
support, high dose Penicillin started in the ED. She survived completely
intact.

20 yo Dartmouth student, s/p splenectomy at 14 yo from trampoline fall,
unknown vaccination status, came to ED awake and talking with fairly
generalized abdominal pain initially. Progressively worse with declining
mental status and hypotension, taken for full ICU support, and died within
36 hours of presentation of MSOF and refractory hypotension. Meningococcus
cultured from her blood. Certainly other college students have died from
meningococcal meningitis that have their spleens intact but it makes you
wonder. 

19 yo skier, crashed and underwent splenectomy. At that time there was
enthusiasm for splenic implantation, so I cut up his spleen and implanted it
in his omentum. He was vaccinated post op. He did well initially and out of
interest I did a liver spleen scan 3 months later and saw several areas
consistent with splenic regeneration in the LUQ. That seemed pretty neat
until he presented 6 months later with a massive streptococcal pharyngeal
abscess requiring drainage and difficult airway management issues. Again,
can't say it had something to do with the splenectomy but it is pretty
unusual for an otherwise healthy kid to get such a problem. This also showed
me, as others subsequently proved, that a critical "mass" of functioning
splenic tissue is important and not just little implants.

The trauma population is the least likely to develop OPSI after splenectomy
compared to those that had the spleen removed for hematologic malignancies
or things like thalassemia. Experience with rheumatic fever pts. shows long
term, daily compliance of taking antibiotic prophylaxis is <40% so I don't
have pts. take daily antibiotics. They get a Rx for penicillin and keep it
filled at home with instructions to take it for any febrile URI type illness
as the first pt. did. They do get vaccinated before they leave the hospital,
not immediately post op because of the possible fever and a blunted antibody
response. (I never had so many pts. at once immediately post op from
splenectomy that I couldn't remember to have them get their vaccines!). The
degree of measured antibody levels to the different components in the 23
type vaccine (which may take up to 6 weeks to achieve maximal levels) also
varies between individuals which makes it difficult to predict how
"protective" vaccination is.

While likely very rare and never able to be studied adequately if you see
any of these pts. it really is frightening. Watching that beautiful young
Dartmouth student crash and die despite everything multiple intelligent,
good people were trying to do for her was a horrible experience.

John Sutton


John E. Sutton, Jr, MD FACS
Staff General Surgeon VAMC
215 North Main Street (112)
White River Junction, VT 05009
802-295-9363 ext. 6194 (office)
802-291-6262 (fax)
Email   john.sutton2 at va.gov

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Matthieu G.
Sent: Thursday, November 25, 2010 8:52 AM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: splenectomy and vaccination

43 y.o. patient, had a splenectomy 17 years ago after an accidental gunshot
wound but otherwise perfectly healthy. Wasnt vaccinated against
pneumococcus. Presents to the ER with a 2 days history of flu-like symptoms
and now a purpuric rash. Rapidly goes into full blown septic shock and
requires mechanical ventilation for 2 weeks and renal replacement therapy.
All the initial blood culture grows a pneumococcus but the primary
infectious source is never found. The patient eventualy recovers but with
ESRD and is now awaiting a renal transplant. 

Of course this is anecdotal and association doesnt mean causation, but...

Matthieu


Le 25 Nov 2010 à 04:24, "Nikahat Jahan" <nikahat at gmail.com> a écrit :

> Thanks everyone for responding to this query. Would highly appreciate if
> someone could share their experience of managing OPSI cases.
> Happy Thanksgiving
> nikahat
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