- Email: [email protected]
Primary Care of the Blunt Splenic Injured Adult
REVIEW
Primary Care of the Blunt Splenic Injured Adult Brian K. Yorkgitis, PA-C, DO Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine Jacksonville.
ABSTRACT The spleen is the most commonly injured abdominal organ in blunt trauma. Immediate treatment is aimed at assessing for bleeding and abating it when it is severe. Methods for the management of blunt splenic injuryeassociated bleeding include observation, splenectomy, and splenic salvage procedures through splenorrhaphy or embolization. After blunt splenic injury, complications commonly occur, including bleeding, infection, thrombosis, and pneumonia. If a patient undergoes splenectomy, infections can be severe. To mitigate infectious complications after splenectomy, vaccination against common pathogens remains paramount. Patients may often present to their primary care provider with complaints related to splenic injury or long-term care of their immunocompromised state. Knowledge of the spleen’s function, as well as common complications and risks, is important to physicians caring for splenic injury patients. This narrative review provides clinicians an understanding of the spleen’s immune function and management strategies for patients sustaining blunt splenic injury. Ó 2016 Elsevier Inc. All rights reserved. The American Journal of Medicine (2017) 130, 365.e1-365.e5 KEYWORDS: Post-splenic injury infection; Spleen injury; Splenectomy; Vaccination
The spleen is one of the most frequently injured abdominal organs in adult trauma patients. Given its high frequency of injury, blunt splenic injury is the most frequent source of major bleeding in abdominal trauma.1 Several modalities have been used to manage bleeding in splenic injuries. These include embolization, splenic preservation procedures, and splenectomy. These life-saving management procedures may render a patient asplenic.2 The spleen plays an important role in immune function. It comprises more than 25% of the total lymphoid mass, making it the largest lymphoid organ in the body.3,4 The immune function of the spleen is important for opsonization of encapsulated organisms.4 Thus, asplenic individuals are at risk for infections, particularly encapsulated organisms.5 Vaccination against these organisms provides patients protection from associated infections. The pathogens that vaccinations are commonly administered against include
Funding: None. Conflict of Interest: None. Authorship: The author had the sole role in writing the manuscript and access to all data. Requests for reprints should be addressed to Brian K. Yorkgitis, PA-C, DO, Department of Surgery, Division of Acute Care Surgery, University of Florida College of Medicine Jacksonville, 653 West 8th Street, Jacksonville, FL 32209. E-mail address: [email protected]fl.edu 0002-9343/$ -see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2016.10.010
Streptococcus pneumoniae, Haemophilus influenza, and Neisseria meningitidis.5 Recently, the US Centers for Disease Control and Prevention (CDC) has updated postsplenectomy vaccination recommendations.6 Here a review of the spleen’s function, as well as common management strategies and complications to assist clinicians caring for blunt splenic injured patients throughout the healthcare continuum, is provided. These patients often present to their physician for ongoing care and complaints that may be related to their blunt splenic injury.
SPLEEN FUNCTION The spleen acts as a filter for blood-borne pathogens and antigens, in addition to its responsibilities in iron metabolism and erythrocyte homeostasis. The spleen is structured in a manner to achieve these functions through regions called red pulp and white pulp. These 2 regions are separated by an interface, the marginal zone.7
Red Pulp The red pulp functions to filter blood and recycle iron from maturing red blood cells. Macrophages inside the red pulp phagocytize old and damaged red cells and blood-borne particulate matter. Iron from destroyed red blood cells is either released for use in the body or stored by the spleen as
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The American Journal of Medicine, Vol 130, No 3, March 2017
ferritin. Larger amounts of ferritin are transformed to hesplenic injury score, the higher the failure rate of observamosiderin for additional storage in the red pulp.7,8 In addition.12-14 For low-grade splenic injuries (AAST I-III) the tion to destruction of damaged or aging red cells, it aids in failure rate remains under 5%, but it increases with grade IV the maturation of reticulocytes.4 Extramedullary hemato(23%) and V (63%) according to one study.14 8 poiesis can occur in the red pulp, particularly in early life. Immunologic function of red pulp macrophages includes Splenectomy secretion of molecules that interfere Splenectomy has historically been with certain iron-requiring pathothe treatment of choice in manCLINICAL SIGNIFICANCE gens’ uptake of iron, thus limiting aging splenic injury hemorrhage. their growth. Additionally, plasma The spleen is the most common abdomFor patients suffering from blasts and plasma cells lodge in the inal organ injured in trauma. exsanguination from the spleen, it red pulp after antigen-specific difremains the preferred method of Observation, splenectomy, embolization, ferentiation in the white pulp. This management. It is also commonly or splenic salvage procedures are methods location allows rapid entry of antiperformed when a patient with a 7 bodies into the blood stream. of managing blunt splenic trauma. splenic injury requires laparotomy Complications are common after splenic for management of other inWhite Pulp juries.15 The entire spleen is injury; often patients may present to The white pulp is composed of removed with the goal of bleeding their primary care physician for related lymphocytes, macrophages, dencessation, to avoid life-threatening complaints. dritic cells, and plasma cells. It is hemorrhage. It is estimated that After splenectomy, patients are at risk divided into T- and B- cell com20%-35% of blunt splenic injuries for infections, particularly encapsulated partments around an arterial vessel, require splenectomy. This results organisms; appropriate vaccination and each attracted to their specific region in the loss of the immunologic by chemokines.7,9 In the T-cell prompt recognition of infections are functions of the spleen.2 compartment, these cells stand ready needed to improve patient care. to activate and assist in pathogen elimination. In the B-cell compartment, clonal expansion of activated B cells occurs.7 Soluble Splenic Salvage antigens are delivered to this large collection of immunologic One method of controlling hemorrhage from splenic trauma cells, allowing immune recognition and processing.4 is splenic salvage. This method involves operative repair of the injured spleen though application of coagulants, splenorrhaphy, partial splenectomy, or a combination of all Marginal Zone these techniques. The goal is to preserve the spleen and The marginal zone is a distinct region of the spleen designed abate bleeding. Failure of splenic salvage that requires to screen the body’s circulation for antigens and pathogens, splenectomy is estimated between 5% and 12%.2 as well as aid in antigen processing. The immune cells residing in this region are important for clearance of microorganisms and viruses.8 The marginal zone possesses aspects of both adaptive and innate immunity.7
MANAGEMENT OF THE INJURED SPLEEN The goal of management of the injured spleen is to abate bleeding that could be life-threatening. Traditionally, this was accomplished through a laparotomy and splenectomy. In the late 1970s, splenic preservation through various techniques became an alternative to splenectomy.10 In recent decades, splenic preservation has been used via embolization.2 Management is often dictated by the grade of splenic injury. The American Association for the Surgery of Trauma (AAST) Spleen Injury Scale is often used, based on computed tomography findings (Table 1).11
Splenic Embolization Arteriography and embolization of splenic injuries has gained popularity in recent years. Arteriography is used to examine for active bleeding. When no contrast blush is seen, close observation for significant bleeding can be performed. This seems to be most effective in low-grade (I-III) injuries. Prophylactic embolization of these low-grade injuries without contrast blush did not provide advantage in several studies.14,16 When there is contrast extravasation, embolization is often performed. This can be accomplished by splenic artery embolization or selective branch embolization targeted to the culprit vessels. Embolization seems to have significant advantage for higher-grade injuries (IV-V). Failure rates requiring operative intervention occur in approximately 15% of cases.12-14,17
Observation In the hemodynamically acceptable patient who has no other abdominal injuries requiring intervention, monitoring the patient closely is a common practice.12 The higher the
COMPLICATIONS Complications associated with blunt splenic injury are not uncommon. Significant bleeding after initial management is
Yorkgitis
Care of Blunt Splenic Injuries
Table 1 The American Association for the Surgery of Trauma Spleen Injury Scale Grade*
Injury Type
Description
I
Hematoma Laceration Hematoma
Subcapsular, <10% surface area Capsular tear, <1 cm parenchymal depth Subcapsular, 10%-50% surface area, intraparenchymal, <5 cm in diameter 1-3 cm parenchymal depth, which does not involve a trabecular vessel Supcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma >3 cm parenchymal depth or involving trabecular vessels Involving segmental or hilar vessels producing major devascularization (>25% of spleen) Completely shattered spleen Hilar vascular injury, which devascularizes spleen
II
Laceration III
Hematoma
Laceration IV
Laceration
V
Laceration Vascular
Adapted from Moore et al,11 with permission. *Advance one grade for multiple injuries, up to grade III.
365.e3 spectrum and cover penicillin-resistant species along with pseudomonal coverage if gram-negative rods are seen. Antibiotics can be modified once sensitives of cultures are available and clinical improvement is noted. Antibiotics should be administered in conjunction with the standard diagnostic and treatment modalities used in the infected or septic patient, with intensive care support for those with severe illness.5 Asplenic individuals are at risk for other infections, including Capnocytophaga canimorsus from animal or human bites, malaria, Bebesia microti, and other common bacteria. Early initiation of appropriate antimicrobial agents is important when infection is suspected. Educating the patient to their increased risk of infection is paramount. This education has been shown to empower patients to seek medical attention promptly and decrease the risk of severe infection.18,21 Many asplenic patients are unaware of their increased risk of infection and the need to seek immediate care should signs of infection arise. Medical alert cards and bracelets may assist clinicians in identifying these individuals, should the patient be unable to provide the information.21
RETURN TO ACTIVITIES a known complication. Rates of bleeding after nonoperative management are the highest in the first 4 days, with 90% of these events occurring in that time. Additionally, 8% of these events occur 9 days or more after injury, when frequently the patient has been discharged from the hospital. Pseudoaneurysm or arteriovenous fistula development can lead to delayed bleeding in splenic trauma.2 Those at highest risk seem to be older than 40 years, with high traumatic injury burden, or those with grade III or higher splenic injury.1 This is important to the nonsurgical provider because patients may present to their clinic for evaluation of symptoms. Providers must be aware of this occurrence to assist in proper detection of nonoperative management failure. Emergent referral to an appropriate care facility should be done. Pleural effusion, thrombocytosis, splenic infarction, pneumonia, and cyst formation are common after treatment of splenic injury.12,18 Thrombosis of the splenic vessels or portal vein and venous thromboembolism all have been reported.18 Surgical site infection, including splenic abscess after splenectomy, has been reported to be 4.5%, 2.4% in those undergoing embolization, and 1.7% in those undergoing no procedural intervention in the year after injury.19,20 With the spleen’s close proximity to the pancreas and colon, these may also be injured from the traumatic event or during splenic interventions.12 Overwhelming postsplenectomy infection is one of the most serious infectious complications following splenectomy. The life-time risk is estimated at 5%, with most occurring in the first 2 years after splenectomy.18 The most common organism is S. pneumoniae, followed by H. influenza and N. meningitidis. Urgent treatment with appropriate antibiotics covering these species is imperative at the first sign of infection. Agents given should be broad-
There is a paucity of data regarding patients who sustain blunt splenic injury and activity limitation duration. Zarzaur et al22 surveyed trauma surgeons for 2 patient scenarios addressing each grade of injury. For an adult who leads a sedentary lifestyle, most surgeons responded that grade I and II injuries should limit activities for <4 weeks, grade III 4-8 weeks, and grade IV and V >8 weeks. For grade IV and V injuries, 14.6% and 17.7% of respondents would use computed tomography- or ultrasound-demonstrated healing as the criteria to lift activity limitations, respectively. When presented with an adult professional football player, grade I and II blunt splenic injury, the majority of surgeons recommended activity limitations for 4-8 weeks, for grade III >8 weeks, and for grade IV and V the majority recommended imaging-demonstrated healing as the criterion to lift activity restrictions, with >8 weeks being a close second criterion.22 A review of spleen injuries addressing athlete return to play was performed by Juyia and Kerr.23 They recommend an individual approach, with athletes being asymptomatic and back to baseline fitness before returning to unrestricted play; for mild injuries, full restriction for 2 weeks and allowing return to full activity by 6 weeks; with grade III and higher, duration should be more conservative. Routine follow-up imaging is not recommended unless clinically indicated.23
VACCINATION RECOMMENDATIONS Routine vaccination schedules as put forth for the general population should always be followed by the CDC or professional organizations to assist in prevention of disease. Specific vaccination recommendations remain one modality to prevent infectious complication after splenectomy. Typically, patients will receive vaccination for the common
365.e4 Table 2
The American Journal of Medicine, Vol 130, No 3, March 2017 CDC Vaccine Recommendations for Asplenic Patients6
Vaccine
Recommendation
Influenza Pneumococcal 13-valent conjugate (PCV13) Pneumococcal polysaccharide (PPSV23) Meningococcal 4-valent conjugate (MenACWY) or polysaccharide (MPSV4) Meningococcal B (MenB) Haemophilius influenzae type b (Hib)
1 1 1 1
dose annually dose perioperative splenectomy* dose perioperative splenectomy,* revaccinate after 5 y† dose perioperative splenectomy, revaccinate every 5 y with MenACWY Series given according to manufacturer recommendation‡ 1 dose perioperative splenectomy
At any time, PPSV23 should be spaced 8 weeks from last PCV13 dose; PCV13 should be spaced at least 1 year from last dose of PPSV23. CDC ¼ US Centers for Disease Control and Prevention. *If PCV13 given, PPSV23 should be spaced 8 weeks from last PCV13 dose; if PPSV23 given, PCV13 should be spaced at least 1 year from PPSV23 administration. †If most recent PPSV23 was administered at age <65 years, administer another dose at age 65 years, given at least 5 years from last dose. ‡MenB is given as 2-dose series of MenB-4C (Bexsero) given at least 1 month apart or 3-dose series of MenB-FHbp (Trumenba) at 0, 2, and 6 months; the 2 vaccines are not interchangeable; the same preparation given for the complete series.
organisms listed previously, before hospital discharge after splenectomy. It is important to obtain the vaccination record from discharge, to ensure patients received them and note what vaccine preparation was given, given that several preparations of some vaccines are available, particularly S. pneumonia and N. meningitidis. Recently the CDC updated the recommendations for asplenic individuals. A summary of these recommendations for the asplenic adult is compiled in Table 2.6 When a patient undergoes a splenic salvage procedure or embolization, the goal is to abate bleeding and preserve splenic function. The question has been raised regarding immuno-competency after embolization procedures. Unfortunately, in the literature there are varying parameters examined to define immuno-competency. A recent systematic review by Schimmer et al24 revealed that 11 of 12 articles indicated splenic artery embolization results in preserved splenic function. Absence of asplenia in patients undergoing embolization or splenectomy may be seen owing to the presence of accessory spleens. It is estimated that 10%-30% of patients may have an accessory spleen.25
advocated. The patient should begin taking these agents at the first sign of systemic infection and seek immediate medical care.5 Agents include amoxicillin-clavulanate or levofloxacin in the penicillin-allergic patient.18
CONCLUSION With the common occurrence of splenic injury among adult trauma patients, it is important that clinicians be aware of complications and infection prevention strategies. Recognition of nonoperative management failure is paramount to identify complications of hemorrhage. Knowledge of recommended vaccinations can help prevent the known infectious complications in splenectomy patients. After the initial trauma, nonsurgeons are often the clinicians caring for their continued needs. Through education of physicians and a multidisciplinary approach, surgeons and nonsurgeons can help patients with blunt splenic injury identify complications and mitigate morbidity and mortality.
References ANTIBIOTIC PROPHYLAXIS For adults who have undergone splenectomy, data are lacking in recommendations for continued prophylactic antibiotics. Outside North America it is common practice to prescribe lifelong antibiotics, typically to cover pneumococcal infections. Adherence to this regimen is difficult. Resistant isolates would not be covered by standard penicillin-based regimens.18,21,26 This is not a common practice in adults in the United States.27,28 Patients at high risk for infection, such as the elderly, those with previous post-splenectomy infection, failure to respond to pneumococcal vaccination, immunocompromised conditions other than splenectomy, or those treated with immunosuppression agents, should be evaluated for the risks and benefits of prophylaxis.5,18 An antibiotic supply provided to a patient to be taken in the event of fever or other signs of infection is often
1. Olthof D, Joosse P, van der Viles C, et al. Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review. J Trauma Acute Care Surg. 2013;74(2):546-557. 2. Watson GA, Hoffman MK, Peitzman AB. Nonoperative management of blunt splenic injury: what is new? Eur J Emerg Surg. 2015;41:219-228. 3. de Porto APNA, Lammers AJJ, Bennick RJ, et al. Assessment of splenic function. Eur J Clin Microbiol Infect Dis. 2010;29:1465-1473. 4. Sills RH. Splenic function: physiology and splenic hypofunction. Crit Rev Oncol Hematol. 1987;7(1):1-36. 5. Davies JM, Lewis MPN, Wimperis J. Review of the guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a Working Party of Haemato-Oncology Task Force. Br J Haematol. 2011;155:308-317. 6. US Centers for Disease Control and Prevention. Recommended adult immunization schedule, United States - 2016. Available at: www.cdc. gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. Accessed September 29, 2016. 7. Mebius RE, Kraal G. Structure and function of the spleen. Nat Rev Immunol. 2005;5(8):606-616.
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8. Cesta MF. Normal structure, function, and histology of the spleen. Toxicol Pathol. 2006;34:455-465. 9. Bronte V, Pittet MJ. The spleen in local and systemic regulation of immunity. Immunity. 2013;39(5):806-818. 10. Strauch GO. Should we attempt to salvage the injured spleen? Conn Med. 1975;39(9):533-536. 11. Moore EE, Cogbill TH, Malangoni M, et al. Organ injury scaling: spleen and liver. J Trauma Acute Care Surg. 1995;38(3):323-324. 12. Stassen NA, Bhullar I, Cheng JD, et al. Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5):S294-S300. 13. Bhullar I, Frykberg ER, Siragusa D, et al. Selective angiographic embolization of blunt splenic traumatic injuries in adults decreases failure rate of nonoperative management. J Trauma Acute Care Surg. 2012;72(5):1128-1134. 14. Dehli T, Bagenholm A, Trasti NC, et al. The treatment of spleen injuries: a retrospective study. Scand J Trauma Resusc Emerg Med. 2015;23(85):1-6. 15. Post R, Engel D, Pham J, Barrios C. Computed tomography blush and splenic injury: does it always require angioembolization? Am Surg. 2013;79(10):1089-1092. 16. Skattum J, Naess PA, Eken T, Gaarder C. Refining the role of splenic angiographic embolization in high-grade splenic injuries. J Trauma Acute Care Surg. 2013;74(1):100-103. 17. Requarth JA, Agostino RB, Miller PR. Nonoperative management of adult blunt splenic injury with and without splenic artery embolotherapy: a meta-analysis. J Trauma. 2011;71:898-903.
365.e5 18. Buzelé R, Barbier L, Sauvanet A, Fantin B. Medical complications following splenectomy. J Visceral Surg. 2016;153:277-286. 19. Olufajo OA, Rios-Diaz A, Peetz AB, et al. Comparing readmissions and infectious complications of blunt splenic injuries using a statewide database. Surg Inf. 2016;17(2):191-197. 20. Freitas G, Olufajo OA, Hammouda K, et al. Postdischarge complications following nonoperative management of splenic injury. Am J Surg. 2016;211:744-749. 21. Brigden ML. Detection, education and management of the asplenic or hyposplenic patient. Am Fam Physician. 2001;63:499-506. 22. Zarzaur BL, Vashi S, Magnotti LJ, Croce MA, Fabian TC. A survey of the Association for the Surgery of Trauma member practices in the management of blunt splenic injury. J Trauma. 2011;70(5): 1026-1031. 23. Juyia RF, Kerr HA. Return to play after liver and spleen trauma. Sports Health. 2014;6(3):239-245. 24. Schimmer JAG, van der Steeg AFW, Zuidema WP. Splenic function after angioembolization for splenic trauma in children and adults: a systematic review. Injury. 2016;47:525-530. 25. Davidson RN, Wall RA. Prevention and management of infections in patients without a spleen. Clin Microbiol Infect. 2001;7:657-660. 26. Nivargi S, Kirankumar R, Kulkarni U, Hukkeri VB. Accessory spleen in clinical perspective. Natl J Clin Anat. 2014;3(4):229-232. 27. US Centers for Disease Control and Prevention. Pneumococcal disease: prevention. Available at: www.cdc.gov/pneumococcal/clinicians/ prevention.html. Accessed October 1, 2016. 28. Rubin GL, Schaffner W. Clinical practice. Care of the asplenic patient. N Engl J Med. 2014;371(4):349-356.
Primary Care of the Blunt Splenic Injured Adult Brian K. Yorkgitis, PA-C, DO Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine Jacksonville.
ABSTRACT The spleen is the most commonly injured abdominal organ in blunt trauma. Immediate treatment is aimed at assessing for bleeding and abating it when it is severe. Methods for the management of blunt splenic injuryeassociated bleeding include observation, splenectomy, and splenic salvage procedures through splenorrhaphy or embolization. After blunt splenic injury, complications commonly occur, including bleeding, infection, thrombosis, and pneumonia. If a patient undergoes splenectomy, infections can be severe. To mitigate infectious complications after splenectomy, vaccination against common pathogens remains paramount. Patients may often present to their primary care provider with complaints related to splenic injury or long-term care of their immunocompromised state. Knowledge of the spleen’s function, as well as common complications and risks, is important to physicians caring for splenic injury patients. This narrative review provides clinicians an understanding of the spleen’s immune function and management strategies for patients sustaining blunt splenic injury. Ó 2016 Elsevier Inc. All rights reserved. The American Journal of Medicine (2017) 130, 365.e1-365.e5 KEYWORDS: Post-splenic injury infection; Spleen injury; Splenectomy; Vaccination
The spleen is one of the most frequently injured abdominal organs in adult trauma patients. Given its high frequency of injury, blunt splenic injury is the most frequent source of major bleeding in abdominal trauma.1 Several modalities have been used to manage bleeding in splenic injuries. These include embolization, splenic preservation procedures, and splenectomy. These life-saving management procedures may render a patient asplenic.2 The spleen plays an important role in immune function. It comprises more than 25% of the total lymphoid mass, making it the largest lymphoid organ in the body.3,4 The immune function of the spleen is important for opsonization of encapsulated organisms.4 Thus, asplenic individuals are at risk for infections, particularly encapsulated organisms.5 Vaccination against these organisms provides patients protection from associated infections. The pathogens that vaccinations are commonly administered against include
Funding: None. Conflict of Interest: None. Authorship: The author had the sole role in writing the manuscript and access to all data. Requests for reprints should be addressed to Brian K. Yorkgitis, PA-C, DO, Department of Surgery, Division of Acute Care Surgery, University of Florida College of Medicine Jacksonville, 653 West 8th Street, Jacksonville, FL 32209. E-mail address: [email protected]fl.edu 0002-9343/$ -see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjmed.2016.10.010
Streptococcus pneumoniae, Haemophilus influenza, and Neisseria meningitidis.5 Recently, the US Centers for Disease Control and Prevention (CDC) has updated postsplenectomy vaccination recommendations.6 Here a review of the spleen’s function, as well as common management strategies and complications to assist clinicians caring for blunt splenic injured patients throughout the healthcare continuum, is provided. These patients often present to their physician for ongoing care and complaints that may be related to their blunt splenic injury.
SPLEEN FUNCTION The spleen acts as a filter for blood-borne pathogens and antigens, in addition to its responsibilities in iron metabolism and erythrocyte homeostasis. The spleen is structured in a manner to achieve these functions through regions called red pulp and white pulp. These 2 regions are separated by an interface, the marginal zone.7
Red Pulp The red pulp functions to filter blood and recycle iron from maturing red blood cells. Macrophages inside the red pulp phagocytize old and damaged red cells and blood-borne particulate matter. Iron from destroyed red blood cells is either released for use in the body or stored by the spleen as
365.e2
The American Journal of Medicine, Vol 130, No 3, March 2017
ferritin. Larger amounts of ferritin are transformed to hesplenic injury score, the higher the failure rate of observamosiderin for additional storage in the red pulp.7,8 In addition.12-14 For low-grade splenic injuries (AAST I-III) the tion to destruction of damaged or aging red cells, it aids in failure rate remains under 5%, but it increases with grade IV the maturation of reticulocytes.4 Extramedullary hemato(23%) and V (63%) according to one study.14 8 poiesis can occur in the red pulp, particularly in early life. Immunologic function of red pulp macrophages includes Splenectomy secretion of molecules that interfere Splenectomy has historically been with certain iron-requiring pathothe treatment of choice in manCLINICAL SIGNIFICANCE gens’ uptake of iron, thus limiting aging splenic injury hemorrhage. their growth. Additionally, plasma The spleen is the most common abdomFor patients suffering from blasts and plasma cells lodge in the inal organ injured in trauma. exsanguination from the spleen, it red pulp after antigen-specific difremains the preferred method of Observation, splenectomy, embolization, ferentiation in the white pulp. This management. It is also commonly or splenic salvage procedures are methods location allows rapid entry of antiperformed when a patient with a 7 bodies into the blood stream. of managing blunt splenic trauma. splenic injury requires laparotomy Complications are common after splenic for management of other inWhite Pulp juries.15 The entire spleen is injury; often patients may present to The white pulp is composed of removed with the goal of bleeding their primary care physician for related lymphocytes, macrophages, dencessation, to avoid life-threatening complaints. dritic cells, and plasma cells. It is hemorrhage. It is estimated that After splenectomy, patients are at risk divided into T- and B- cell com20%-35% of blunt splenic injuries for infections, particularly encapsulated partments around an arterial vessel, require splenectomy. This results organisms; appropriate vaccination and each attracted to their specific region in the loss of the immunologic by chemokines.7,9 In the T-cell prompt recognition of infections are functions of the spleen.2 compartment, these cells stand ready needed to improve patient care. to activate and assist in pathogen elimination. In the B-cell compartment, clonal expansion of activated B cells occurs.7 Soluble Splenic Salvage antigens are delivered to this large collection of immunologic One method of controlling hemorrhage from splenic trauma cells, allowing immune recognition and processing.4 is splenic salvage. This method involves operative repair of the injured spleen though application of coagulants, splenorrhaphy, partial splenectomy, or a combination of all Marginal Zone these techniques. The goal is to preserve the spleen and The marginal zone is a distinct region of the spleen designed abate bleeding. Failure of splenic salvage that requires to screen the body’s circulation for antigens and pathogens, splenectomy is estimated between 5% and 12%.2 as well as aid in antigen processing. The immune cells residing in this region are important for clearance of microorganisms and viruses.8 The marginal zone possesses aspects of both adaptive and innate immunity.7
MANAGEMENT OF THE INJURED SPLEEN The goal of management of the injured spleen is to abate bleeding that could be life-threatening. Traditionally, this was accomplished through a laparotomy and splenectomy. In the late 1970s, splenic preservation through various techniques became an alternative to splenectomy.10 In recent decades, splenic preservation has been used via embolization.2 Management is often dictated by the grade of splenic injury. The American Association for the Surgery of Trauma (AAST) Spleen Injury Scale is often used, based on computed tomography findings (Table 1).11
Splenic Embolization Arteriography and embolization of splenic injuries has gained popularity in recent years. Arteriography is used to examine for active bleeding. When no contrast blush is seen, close observation for significant bleeding can be performed. This seems to be most effective in low-grade (I-III) injuries. Prophylactic embolization of these low-grade injuries without contrast blush did not provide advantage in several studies.14,16 When there is contrast extravasation, embolization is often performed. This can be accomplished by splenic artery embolization or selective branch embolization targeted to the culprit vessels. Embolization seems to have significant advantage for higher-grade injuries (IV-V). Failure rates requiring operative intervention occur in approximately 15% of cases.12-14,17
Observation In the hemodynamically acceptable patient who has no other abdominal injuries requiring intervention, monitoring the patient closely is a common practice.12 The higher the
COMPLICATIONS Complications associated with blunt splenic injury are not uncommon. Significant bleeding after initial management is
Yorkgitis
Care of Blunt Splenic Injuries
Table 1 The American Association for the Surgery of Trauma Spleen Injury Scale Grade*
Injury Type
Description
I
Hematoma Laceration Hematoma
Subcapsular, <10% surface area Capsular tear, <1 cm parenchymal depth Subcapsular, 10%-50% surface area, intraparenchymal, <5 cm in diameter 1-3 cm parenchymal depth, which does not involve a trabecular vessel Supcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma >3 cm parenchymal depth or involving trabecular vessels Involving segmental or hilar vessels producing major devascularization (>25% of spleen) Completely shattered spleen Hilar vascular injury, which devascularizes spleen
II
Laceration III
Hematoma
Laceration IV
Laceration
V
Laceration Vascular
Adapted from Moore et al,11 with permission. *Advance one grade for multiple injuries, up to grade III.
365.e3 spectrum and cover penicillin-resistant species along with pseudomonal coverage if gram-negative rods are seen. Antibiotics can be modified once sensitives of cultures are available and clinical improvement is noted. Antibiotics should be administered in conjunction with the standard diagnostic and treatment modalities used in the infected or septic patient, with intensive care support for those with severe illness.5 Asplenic individuals are at risk for other infections, including Capnocytophaga canimorsus from animal or human bites, malaria, Bebesia microti, and other common bacteria. Early initiation of appropriate antimicrobial agents is important when infection is suspected. Educating the patient to their increased risk of infection is paramount. This education has been shown to empower patients to seek medical attention promptly and decrease the risk of severe infection.18,21 Many asplenic patients are unaware of their increased risk of infection and the need to seek immediate care should signs of infection arise. Medical alert cards and bracelets may assist clinicians in identifying these individuals, should the patient be unable to provide the information.21
RETURN TO ACTIVITIES a known complication. Rates of bleeding after nonoperative management are the highest in the first 4 days, with 90% of these events occurring in that time. Additionally, 8% of these events occur 9 days or more after injury, when frequently the patient has been discharged from the hospital. Pseudoaneurysm or arteriovenous fistula development can lead to delayed bleeding in splenic trauma.2 Those at highest risk seem to be older than 40 years, with high traumatic injury burden, or those with grade III or higher splenic injury.1 This is important to the nonsurgical provider because patients may present to their clinic for evaluation of symptoms. Providers must be aware of this occurrence to assist in proper detection of nonoperative management failure. Emergent referral to an appropriate care facility should be done. Pleural effusion, thrombocytosis, splenic infarction, pneumonia, and cyst formation are common after treatment of splenic injury.12,18 Thrombosis of the splenic vessels or portal vein and venous thromboembolism all have been reported.18 Surgical site infection, including splenic abscess after splenectomy, has been reported to be 4.5%, 2.4% in those undergoing embolization, and 1.7% in those undergoing no procedural intervention in the year after injury.19,20 With the spleen’s close proximity to the pancreas and colon, these may also be injured from the traumatic event or during splenic interventions.12 Overwhelming postsplenectomy infection is one of the most serious infectious complications following splenectomy. The life-time risk is estimated at 5%, with most occurring in the first 2 years after splenectomy.18 The most common organism is S. pneumoniae, followed by H. influenza and N. meningitidis. Urgent treatment with appropriate antibiotics covering these species is imperative at the first sign of infection. Agents given should be broad-
There is a paucity of data regarding patients who sustain blunt splenic injury and activity limitation duration. Zarzaur et al22 surveyed trauma surgeons for 2 patient scenarios addressing each grade of injury. For an adult who leads a sedentary lifestyle, most surgeons responded that grade I and II injuries should limit activities for <4 weeks, grade III 4-8 weeks, and grade IV and V >8 weeks. For grade IV and V injuries, 14.6% and 17.7% of respondents would use computed tomography- or ultrasound-demonstrated healing as the criteria to lift activity limitations, respectively. When presented with an adult professional football player, grade I and II blunt splenic injury, the majority of surgeons recommended activity limitations for 4-8 weeks, for grade III >8 weeks, and for grade IV and V the majority recommended imaging-demonstrated healing as the criterion to lift activity restrictions, with >8 weeks being a close second criterion.22 A review of spleen injuries addressing athlete return to play was performed by Juyia and Kerr.23 They recommend an individual approach, with athletes being asymptomatic and back to baseline fitness before returning to unrestricted play; for mild injuries, full restriction for 2 weeks and allowing return to full activity by 6 weeks; with grade III and higher, duration should be more conservative. Routine follow-up imaging is not recommended unless clinically indicated.23
VACCINATION RECOMMENDATIONS Routine vaccination schedules as put forth for the general population should always be followed by the CDC or professional organizations to assist in prevention of disease. Specific vaccination recommendations remain one modality to prevent infectious complication after splenectomy. Typically, patients will receive vaccination for the common
365.e4 Table 2
The American Journal of Medicine, Vol 130, No 3, March 2017 CDC Vaccine Recommendations for Asplenic Patients6
Vaccine
Recommendation
Influenza Pneumococcal 13-valent conjugate (PCV13) Pneumococcal polysaccharide (PPSV23) Meningococcal 4-valent conjugate (MenACWY) or polysaccharide (MPSV4) Meningococcal B (MenB) Haemophilius influenzae type b (Hib)
1 1 1 1
dose annually dose perioperative splenectomy* dose perioperative splenectomy,* revaccinate after 5 y† dose perioperative splenectomy, revaccinate every 5 y with MenACWY Series given according to manufacturer recommendation‡ 1 dose perioperative splenectomy
At any time, PPSV23 should be spaced 8 weeks from last PCV13 dose; PCV13 should be spaced at least 1 year from last dose of PPSV23. CDC ¼ US Centers for Disease Control and Prevention. *If PCV13 given, PPSV23 should be spaced 8 weeks from last PCV13 dose; if PPSV23 given, PCV13 should be spaced at least 1 year from PPSV23 administration. †If most recent PPSV23 was administered at age <65 years, administer another dose at age 65 years, given at least 5 years from last dose. ‡MenB is given as 2-dose series of MenB-4C (Bexsero) given at least 1 month apart or 3-dose series of MenB-FHbp (Trumenba) at 0, 2, and 6 months; the 2 vaccines are not interchangeable; the same preparation given for the complete series.
organisms listed previously, before hospital discharge after splenectomy. It is important to obtain the vaccination record from discharge, to ensure patients received them and note what vaccine preparation was given, given that several preparations of some vaccines are available, particularly S. pneumonia and N. meningitidis. Recently the CDC updated the recommendations for asplenic individuals. A summary of these recommendations for the asplenic adult is compiled in Table 2.6 When a patient undergoes a splenic salvage procedure or embolization, the goal is to abate bleeding and preserve splenic function. The question has been raised regarding immuno-competency after embolization procedures. Unfortunately, in the literature there are varying parameters examined to define immuno-competency. A recent systematic review by Schimmer et al24 revealed that 11 of 12 articles indicated splenic artery embolization results in preserved splenic function. Absence of asplenia in patients undergoing embolization or splenectomy may be seen owing to the presence of accessory spleens. It is estimated that 10%-30% of patients may have an accessory spleen.25
advocated. The patient should begin taking these agents at the first sign of systemic infection and seek immediate medical care.5 Agents include amoxicillin-clavulanate or levofloxacin in the penicillin-allergic patient.18
CONCLUSION With the common occurrence of splenic injury among adult trauma patients, it is important that clinicians be aware of complications and infection prevention strategies. Recognition of nonoperative management failure is paramount to identify complications of hemorrhage. Knowledge of recommended vaccinations can help prevent the known infectious complications in splenectomy patients. After the initial trauma, nonsurgeons are often the clinicians caring for their continued needs. Through education of physicians and a multidisciplinary approach, surgeons and nonsurgeons can help patients with blunt splenic injury identify complications and mitigate morbidity and mortality.
References ANTIBIOTIC PROPHYLAXIS For adults who have undergone splenectomy, data are lacking in recommendations for continued prophylactic antibiotics. Outside North America it is common practice to prescribe lifelong antibiotics, typically to cover pneumococcal infections. Adherence to this regimen is difficult. Resistant isolates would not be covered by standard penicillin-based regimens.18,21,26 This is not a common practice in adults in the United States.27,28 Patients at high risk for infection, such as the elderly, those with previous post-splenectomy infection, failure to respond to pneumococcal vaccination, immunocompromised conditions other than splenectomy, or those treated with immunosuppression agents, should be evaluated for the risks and benefits of prophylaxis.5,18 An antibiotic supply provided to a patient to be taken in the event of fever or other signs of infection is often
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