Tag Archives: vaccine

When to Give Spleen Vaccines After Splenectomy for Trauma

I’ve written previously on the (f)utility of giving vaccines after splenectomy for trauma (click here to read). However, it is more or less a medicolegal standard, so pretty much everyone gives them. The big question is, when? 

Some centers give them immediately postop, some before hospital discharge, and some during their postop visit. Who is right? The argument is that major surgery produces some degree of immunocompromise. So if the vaccines are given too early, perhaps the anitbodies will not be processed as effectively, and the response to an actual bacterial challenge might not be as good.

One prospective study randomized patients to receive their pneumococcal vaccine either 1, 7, or 14 days after surgery. IgG levels were measured before vaccination and again after 4 weeks. This study found that antibody concentrations were the same in all groups. However, functional activity of the antibodies was low in the 1 and 7 day groups, and nearly normal in the 14 day group.

Following this, a rat study looked at vaccination timing followed by exposure to pneumococcus. These animals were splenectomized, then given a real or sham vaccination at 1, 7, or 42 days. They then had pneumococcus injected into their peritoneal cavity. About 70% of all rats with sham vaccination died. Only 1.5% of the vaccinated rats died, and there were no differences based on vaccination timing.

Bottom line: Neither antibody titer studies nor rat studies easily translate into recommendations for treating overwhelming post-splenectomy sepsis (OPSS) in humans. And such a study can never be done because of the rarity of this condition (less than 70 cases since the beginning of time). It really boils down to your specific population, balancing your assurance that your patient will get it against the possibility that their immune system may not react to it as much as it could. 

At our center, we give the vaccines as soon as possible postoperatively. This ensures that it is given, and erases any doubt of what might happen if the patient does not show up for their postop check.

References:

  • Immune responses of splenectomized trauma patietns to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. J Trauma 44(5):760-766, 1998.
  • Timing of vaccination does not affect antibody response or survival after pneumococcal challenge in splenectomized rats. J Trauma 45(4):682-697, 1998.

Related posts:

    Vaccines After Splenic Trauma

    The current standard of care is to vaccinate patients after splenectomy to prevent overwhelming post-splenectomy sepsis (OPSS). The real questions are, is this reasonable and is it needed after splenorrhaphy or angioembolization, too?

    The spleen was recognized as contributing to infection resistance in the early 1900s. A study on post-splenectomy sepsis that has been widely quoted was published in 1952. Unfortunately, the children involved all had hematologic disorders, so it is difficult to determine if their sepsis deaths were due to splenectomy or their underlying disease.

    Reports of sepsis and death continued to accumulate in the latter half of the last century, but there was a tremendous amount of overlap in patient cases. Richardson reviewed the world literature to date and found that, as of about 2003, there were roughly 70 total cases worldwide since the beginning of time, with a death rate of about 30%. Basically, there are more published papers and reports on death from OPSS than there are actual cases!

    This flawed data directed a push toward splenorrhaphy and then to nonoperative management of splenic injury. Guidelines have been developed and revised that suggest that the following vaccines should be given to patients with splenectomy:

    • Pneumovax 23 – .5cc SQ, booster every 6 years
    • Haemophilus B conjugate – .5cc IM, no booster
    • Meningococcal vaccine (polysaccharide or diphtheria conjugate) – .5cc (route depends on vaccine), booster status unclear

    There is no good data at all on vaccine administration after angioembolization. Animal studies suggest that at least 50% of the spleen must be perfused by the splenic artery in order to maintain immune competence. Patients who have CT or angiographic evidence that a significant portion of the spleen is not perfused should probably undergo vaccination.

    Given the rarity of OPSS and the even lower probability of dying from it, a definitive study regarding the usefulness of spleen vaccine administration will never be done. So we are stuck with giving them in spleen-injured or spleen-free patients even though the usefulness can never be proven.

    Reference: J David Richardson. Managing Liver and Spleen Injuries. J Am Col Surg 200(5):648-669, 2005.