ICIS
Intercontinental Cooperative ITP Study Group
/
Please fill out this questionnaire and e-mail it to:
University Children’s Hospital
ICIS Study Group
Postfach
CH-4031 Basel, Switzerland
FAX: +41 61 704 12 41 / UPN: / Study Number:
Name of participating physician City / State / Country
History of ITP before splenectomy
1.Primary ITP
2.Secondary ITP, reason(s):
Diagnostic procedures and therapy before splenectomy
3.Bleeding signs at admission for splenectomy
NoYes, details:
skin bleeding only mucosal bleeding
4.Platelet count at admission for splenectomy
x109/LDate//
(dd/mm/yyyy)
5.Laboratory tests before splenectomy
Platelet antigen-
specific antibodiesnot donedone,Result: Date //
(dd/mm/yyyy)
Bone marrownot donedone,Result: Date //
(dd/mm/yyyy)
6.Attempts to treat ITP before splenectomy
IVIgoral PrednisoneIV anti-Rh(D) oral Dexamethasone
IV Methylprednisoloneother:
Management before splenectomy
7.Immunization pre-splenectomy
No Immunization
PneumococcusDate:1)// 2) // 3) // 4) //
(dd/mm/yy)(dd/mm/yy)(dd/mm/yy)(dd/mm/yy)
H. Influenzae Date:1)// 2) // 3) // 4) //
(dd/mm/yy)(dd/mm/yy)(dd/mm/yy)(dd/mm/yy)
MeningococciDate:1)// 2) // 3) // 4) //
(dd/mm/yy)(dd/mm/yy)(dd/mm/yy)(dd/mm/yy)
Date:1)// 2) // 3) // 4) //
(dd/mm/yy)(dd/mm/yy)(dd/mm/yy)(dd/mm/yy)
8.Adjuvant therapy to enable splenectomy (to raise platelet count)
Therapy (Prednison, IVIg, etc.)
Start of that therapy (number of days, not the date) before splenectomy: days
Duration of that therapy days
9.Laboratory tests immediately before splenectomy
Platelet count x109/L; hours before surgery
PTseconds; hours before surgery
aPTTseconds; hours before surgery
Bleeding timeminutes; hours before surgery
Other tests:
Splenectomy
10.Date of splenectomy:// Date of admission: //
(dd/mm/yyyy) (dd/mm/yyyy)
11.Date of discharge from hospital//
(dd/mm/yyyy)
12.Open splenectomyLaparoscopic splenectomy
13.Accessory spleensNoYes; Removed completely No Yes
14.Complications related to splenectomy
Bleeding; Packed red blood cell (PRBC) supply during surgery: ml PRBC
Fever without any other signs of sepsis; during surgery; hours after surgery
Overwhelming post-splenectomy sepsis; date of diagnosis: //
(dd/mm/yyyy)
Others:
Management post splenectomy
15.Post-splenectomy antibiotic prophylaxis
Noif fever present only Yes; Antibiotic (generic name):
Schedule:daily other schedule:
Duration of post-splenectomy antibiotic prophylaxis:
lifelongyears days
16.Gammaglobulins (IVIg) after splenectomyNoYes
17.Other platelet enhancing therapy post splenectomy:
18.Response to splenectomy (plt x109/L)
(day 0 = day of splenectomy = date://,
Frequency of platelet counts remain at your decision)
Recommended Dayactual Dayplatelet count
0
2
3
4
5
6 - 10
11 - 15
16 - 20
21 - 25
26 - 30
31 - 60
61 - 90
19. What is your follow-up program for your patient?
consultation ever days
other schedule:
20.Consultations are performed by
HematologistGeneral practitionerOther:
Version 1,0 10/2010 ICIS Splenectomy Registry 1 st Sheet page 1/3