Moore Retreat: Spleen

Immunizations:
Boosters given;
- Pneumococcus @ 5yrs
- no boosters given for HIB or meningococcus
- Influenza vaccine given qYr
- EEM ideally gives vaccinations 2-3 weeks post-op; if the patient is unreliable then he will give @ time of discharge
- grade 4-5 and transfused 1-2U pRBC, will give immunizations

Prophylactic Antibiotics:
- Amoxicillin or Erythromycin prophylaxis given from 3-5 yo
- @ UAH pediatricians suggest until age of 7 yo

Unlike liver; 
- spleen can bleed in a delayed fashion, even 7-10d out from injury
- Even grade 1-2 injuries can bleed significantly

Conservative Treatment:
Grade 1-3:
- AAT, DAT - let the responsible adult manage and D/C when they see fit.
- D/C pack qD when pt feels fit
Grade 4-5:
- U/S follow-up as outpatient - no need  for inpatient CT.

Angio:
- Does a contrast blush mandate angio?
- pts can have either an arterial or venous blush, location of blush matters too
- EEM uses this information to determine if pt to get angio; uses angio selectively
- Global embolization of splenic artery has a propensity to result in splenic abscess formation which can be much more challenging compared to a splenectomy would have been
- when patient hemocontracted what seems like a smaller subsegmental branch can in fact be a larger segmental branch and embolization can result in significant devascularization of spleen

Unstable Patient:
- open the lesser sac and clamp the hilum before mobilizing the spleen
- cut the ligaments 1-2 cm beyond the capsule of the spleen to prevent causing more bleeding by avulsing the capsule
- if you stay right on the the kidney when dividing the splenorenal ligament you avoid getting into the tail of the pancreas

Transfusion triggers to take out spleen:
- recurrent hypotension after 2U pRBC
- EEM aggressive in taking our spleen, risk of OPSS minimal in adult

OPSS:
- rare in adults,
- in children >2 yo rate is higher but salvage rate is 98%
- really of most concern in very young patients  < 2 yo

DVT Prophylaxis in pts with splenic injury:
- use of Thromboelastogram? Some pts resistant to LMWH and may need antiplatelet therapy (for upto 4 weeks)
- when deciding to anticoagulate in pt with splenic injury, consider that preventing a PE is probably much more important than preventing the spleen from coming out

Splenic Autotransplantation:
- In Denver they routinely autotransplant splenic fragments into an omental pouch
- there is retrospective data that demonstrates that autotransplanted pts have increased IgA, IgM and Tuftsin levels