Please fill out this questionnaire and e-mail or fax it to:

SPLENECTOMY REGISTRY
Intercontinental Cooperative ITP Study Group
www.itpbasel.ch


Please fill out this questionnaire and e-mail it to:
Postfach CH-4031 Basel, Switzerland FAX: +41 61 704 12 41 History of ITP before splenectomy

1.

2.
Diagnostic procedures and therapy before splenectomy

3.
Bleeding signs at admission for splenectomy

4.
Platelet count at admission for splenectomy
x109/L Date / /

5.
Laboratory tests before splenectomy

6.
Attempts to treat ITP before splenectomy
Version 1,0 10/2010 ICIS Splenectomy Registry 1 st Sheet page 1/3 SPLENECTOMY REGISTRY
Intercontinental Cooperative ITP Study Group
www.itpbasel.ch
Management before splenectomy

7. Immunization
pre-splenectomy
Date: 1) / / 2)
/ / 3)
/ / 4) / /
Date: 1) / / 2)
/ / 3)
/ / 4) / /
Date: 1) / / 2)
/ / 3)
/ / 4) / /
/ / 2)
/ / 3)
/ / 4) / /

8.
Adjuvant therapy to enable splenectomy (to raise platelet count)
Start of that therapy (number of days, not the date) before splenectomy:
9.
Laboratory tests immediately before splenectomy
Splenectomy

10. Date of splenectomy:
/ /
Date of admission: / /

11. Date of discharge from hospital
/ /

12. Open splenectomy
Laparoscopic splenectomy

13. Accessory
spleens

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: / /
Version 1,0 10/2010 ICIS Splenectomy Registry 1 st Sheet page 2/3 SPLENECTOMY REGISTRY
Intercontinental Cooperative ITP Study Group
www.itpbasel.ch
Management post splenectomy
15. Post-splenectomy antibiotic prophylaxis

if fever present only Yes; Antibiotic (generic name): Duration of post-splenectomy antibiotic prophylaxis:
16. Gammaglobulins (IVIg) after splenectomy

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)
19. What is your follow-up program for your patient?


20. Consultations are performed by

Version 1,0 10/2010 ICIS Splenectomy Registry 1 st Sheet page 3/3

Source: http://www.itpbasel.ch/fileadmin/user_upload/itpbasel/downloads/Splenectomy_Registry_-_FIRST-SHEET.pdf?PHPSESSID=dbe5645daf058cde26b98a1518872f74