PEDIATRIC PERIOPERATIVE FLUID THERAPY Evangeline Ko-Villa, MD, DPBA Clinical Associate Professor UP-PGH Department of Anesthesiology.

PEDIATRICPEDIATRICPERIOPERATIVE PERIOPERATIVE FLUID THERAPYFLUID THERAPY

Evangeline Ko-Villa, MD, DPBAEvangeline Ko-Villa, MD, DPBAClinical Associate ProfessorClinical Associate Professor

UP-PGH Department of AnesthesiologyUP-PGH Department of Anesthesiology

ObjectivesObjectives

Review relevant physiological considerations Review relevant physiological considerations in the pediatric populationin the pediatric population

Review how to evaluate intravascular volumeReview how to evaluate intravascular volume

Discuss the different types of IV fluidsDiscuss the different types of IV fluids

Discuss regimens for perioperative fluid and Discuss regimens for perioperative fluid and blood replacement therapyblood replacement therapy

Body Fluid CompartmentsBody Fluid Compartments

TOTAL BODY WATER (60%)

EXTRACELLULAR FLUID

(1/3 TBW)

INTRACELLULAR FLUID

(2/3 TBW)

INTERSTITIAL FLUID

(3/4 ECF)

PLASMA

(1/4 ECF)

TRANSCELLULAR FLUID

Accurate for children 6 months of age and older

Body Fluid CompartmentsBody Fluid Compartments

0

10

20

30

40

50

60

70

80

90

Preterm Term 6months

1 year Adult

Total Body WaterMuscle MassFat

B

o

d

y

C

o

m

p

o

s

i

t

i

o

n

(%)

Body Fluid CompartmentsBody Fluid Compartments

ICF – 2/3 TBWICF – 2/3 TBW

The proportion of ECF is much greater to The proportion of ECF is much greater to that of the ICF in the preterm infants.that of the ICF in the preterm infants.

Upon birth, there is gradual shift from the Upon birth, there is gradual shift from the ECF to the ICFECF to the ICF

Blood VolumesBlood Volumes

Preterm 100 ml/kgPreterm 100 ml/kg Term 90 ml/kgTerm 90 ml/kg Infant 80 ml/kgInfant 80 ml/kg School Age 75 ml/kgSchool Age 75 ml/kg Adult 70 ml/kgAdult 70 ml/kg

Source: A Practice of Anesthesia for Infants and Children by Cote 4th ed

Renal SystemRenal System

Features of a fetal kidney:

low RBF, low GFR

Reasons behind these features:

1. low systemic arterial pressure

2. high renal vascular resistance

3. low permeability of glomerular capillaries

4. small size and number of glomeruli

Renal SystemRenal System

11stst 3 -4 days of life: 3 -4 days of life: circulatory changes circulatory changes ↑ RBF and ↑GFR↑ RBF and ↑GFR

1 month of age: kidneys are 60% 1 month of age: kidneys are 60% mature. This is sufficient to handle mature. This is sufficient to handle almost any contingency.almost any contingency.

2 yrs: complete maturation of renal 2 yrs: complete maturation of renal functionfunction

Renal SystemRenal System

Immature tubular cells cannot completely reabsorb Immature tubular cells cannot completely reabsorb NaNa++ under the stimulus of aldosterone under the stimulus of aldosterone

⇓⇓

Neonate continue to excrete Neonate continue to excrete NaNa+ + in the urine in the urine

despite the presence of a severe Nadespite the presence of a severe Na+ + defectdefect

Implication: “obligate sodium loser”Implication: “obligate sodium loser”

Renal System: Concentrating CapacityRenal System: Concentrating Capacity

Limited in the neonate Limited in the neonate Max urine osmolality is only Max urine osmolality is only ½½ of adult levels of adult levels

(700-800 meq/L vs 1300 – 1400 meq/L)(700-800 meq/L vs 1300 – 1400 meq/L) Contributory factors:Contributory factors: low circulating ADH levelslow circulating ADH levels ↓ ↓ renal responsiveness to ADHrenal responsiveness to ADH ↓ ↓ tonicity in the medulary insterstitiumtonicity in the medulary insterstitium

Implication: Increases free water losses duringImplication: Increases free water losses during excretion of a solute lossexcretion of a solute loss

Renal System: Diluting CapacityRenal System: Diluting Capacity

A water-loaded infant can excrete dilute urine A water-loaded infant can excrete dilute urine with osmolality as low as 50 mOsm/kg. with osmolality as low as 50 mOsm/kg.

The diluting capacity becomes mature by The diluting capacity becomes mature by 3 to 5 weeks of postnatal life.3 to 5 weeks of postnatal life.

Cardiovascular SystemCardiovascular System

relatively low contractile mass/gram of cardiac tissue

⇓limited ability to ↑ myocardial contractility

↓ in ventricular compliance

⇓extremely limited ability to ↑ stroke volume

Implication: need to ↑HR to ↑cardiac output

Cardiovascular SystemCardiovascular System

cardiac Cacardiac Ca2+2+ stores are stores are ↓ due to immaturity ↓ due to immaturity of sacroplasmic reticulum of sacroplasmic reticulum ⇒ dependent ⇒ dependent of exogenous of exogenous CaCa2+2+

Implication: Implication: Neonatal heart is vulnerable to myocardial Neonatal heart is vulnerable to myocardial dysfunction in the presence of citrate-induced dysfunction in the presence of citrate-induced hypocalcemiahypocalcemia

Hematologic SystemHematologic System

Neonates have higher baseline Hb values Neonates have higher baseline Hb values (14 – 20 g/dl)(14 – 20 g/dl)

They have a higher percentage of fetal HbThey have a higher percentage of fetal Hb

At birth, vitamin K dependent factors are at At birth, vitamin K dependent factors are at 20 – 60% of adult levels20 – 60% of adult levels

Neonatal Fluid ManagementNeonatal Fluid Management At birth: ECF is greater than ICFAt birth: ECF is greater than ICF

A few days after birth: A few days after birth:

ECF contraction and wt loss due to ANP induced ECF contraction and wt loss due to ANP induced diuresis 2diuresis 2° to ↑ pulmonary blood flow & stretch of left atrial ° to ↑ pulmonary blood flow & stretch of left atrial receptorsreceptors

This is followed by ↑ water and Na requirements to match This is followed by ↑ water and Na requirements to match those of the growing infantthose of the growing infant

Implication: Implication: Fluids should be restricted until the postnatal Fluids should be restricted until the postnatal weight loss has occurred.weight loss has occurred.

Neonatal Fluid ManagementNeonatal Fluid Management

If a baby requires IV fluids from birth, they shld be given If a baby requires IV fluids from birth, they shld be given 10% dextrose in the following volumes10% dextrose in the following volumesDay 1Day 1 60 ml/kg/day60 ml/kg/day Day 4Day 4 150150Day 2Day 2 9090 Day 5Day 5 150150Day 3Day 3 120120

NaNa++ 3 mmol/kg/day & K 3 mmol/kg/day & K++ 2 mmol/kg/day shld be added 2 mmol/kg/day shld be added after the postnatal diuresis or if Naafter the postnatal diuresis or if Na++ drops drops

A premature neonate may require an additional 30 A premature neonate may require an additional 30 ml/kg/day and additional Naml/kg/day and additional Na++

Neonatal Fluid ManagementNeonatal Fluid Management

Fluid requirements are titrated to the:Fluid requirements are titrated to the:

patient’s changing weightpatient’s changing weight

urine outputurine output

serum sodiumserum sodium

Evaluation of Intravascular VolumeEvaluation of Intravascular Volume

Physical ExaminationPhysical Examination

Laboratory ExamLaboratory Exam

Hemodynamic MeasurementsHemodynamic Measurements

Clinical and laboratory assessment of the severity Clinical and laboratory assessment of the severity

of dehydration in childrenof dehydration in children Signs and Signs and SymptomsSymptoms

Mild Mild DehydrationDehydration

Moderate Moderate DehydrationDehydration

Severe Severe DehydrationDehydration

Wt loss (%)Wt loss (%) 55 1010 1515

Fluid deficit Fluid deficit (ml/kg)(ml/kg)

5050 100100 150150

Vital SignsVital Signs

PulsePulse NormalNormal ↑↑, weak, weak greatly greatly ↑, ↑, feeblefeeble

BPBP NormalNormal Normal to lowNormal to low ↓↓, orthostatic, orthostatic

RespirationRespiration NormalNormal DeepDeep Deep & rapidDeep & rapid

Clinical and laboratory assessment of the Clinical and laboratory assessment of the severity of dehydration in childrenseverity of dehydration in children

Signs and Signs and SymptomsSymptoms

Mild Mild DehydrationDehydration

Moderate Moderate DehydrationDehydration

Severe Severe DehydrationDehydration

BehaviorBehavior NormalNormal IrritableIrritable Hyperirritable Hyperirritable to lethargicto lethargic

ThirstThirst SlightSlight ModerateModerate IntenseIntense

Skin turgorSkin turgor NormalNormal DecreasedDecreased Greatly Greatly ↓↓

Ant. fontanelleAnt. fontanelle NormalNormal SunkenSunken Markedly Markedly depresseddepressed

Urine flow Urine flow (ml/kg/hr)(ml/kg/hr)

<2<2 <1<1 <0.5<0.5

Urine SGUrine SG 1.0201.020 1.020 – 1.0301.020 – 1.030 >1.030>1.030

Choice of fluidsChoice of fluids

CrystalloidsCrystalloids

ColloidsColloids

Blood productsBlood products Whole bloodWhole blood pRBCpRBC FFPFFP PlateletsPlatelets

CrystalloidsCrystalloids

sterile aqueous solutions which may sterile aqueous solutions which may contain glucose, various electrolytes, contain glucose, various electrolytes, organic salts and nonionic compoundsorganic salts and nonionic compounds

rapidly equilibrates with ECFrapidly equilibrates with ECF

Composition of CrystalloidsComposition of Crystalloids

FluidFluid OsmolarityOsmolarity pHpH NaNa KK ClCl GlucoseGlucose

0.9% 0.9% NaClNaCl

308308 6.06.0 154154 00 154154 00

LRLR 273273 6.56.5 130130 44 156156 00

DD55WW 252252 4.54.5 00 00 00 5050

DD55LRLR 525525 5.05.0 130130 44 156156 5050

DD55NRNR 547547 5.25.2 140140 55 00

Crystalloid SolutionsCrystalloid Solutions

2 ways of classification2 ways of classification

a. based on usea. based on use

b. based on tonicity b. based on tonicity

Crystalloid Solutions: Based on UseCrystalloid Solutions: Based on Use

Maintenance-type solutionsMaintenance-type solutions water loss water loss hypotonic solutionshypotonic solutions

Replacement-type solutionsReplacement-type solutions water and electrolyte losses water and electrolyte losses isotonic electrolyte solutionsisotonic electrolyte solutions

Fluids for special purposesFluids for special purposes

Crystalloid Solutions: Based on TonicityCrystalloid Solutions: Based on Tonicity Balanced salt solutionsBalanced salt solutions

electrolyte composition similar to ECFelectrolyte composition similar to ECF Hypotonic with respect to NaHypotonic with respect to Na

FluidFluid OsmOsm pHpH NaNa KK OtherOther

LRLR 273273 6.56.5 130130 44 Lactate = 28Lactate = 28

NormosolNormosol 295295 7.47.4 140140 55 Mg =3, acetate = 27, Mg =3, acetate = 27, gluconate = 23gluconate = 23

PlasmalytePlasmalyte 298.5298.5 5.55.5 140140 55 HCOHCO33 = 50 = 50

Crystalloid Solutions: Based on TonicityCrystalloid Solutions: Based on Tonicity

Normal Saline Normal Saline isotonic (6.0) and isoosmotic (308)isotonic (6.0) and isoosmotic (308) contains no buffers or electrolytescontains no buffers or electrolytes large volume: large volume:

dilutional hyperchloremic acidosisdilutional hyperchloremic acidosis

Crystalloid Solutions: Based on TonicityCrystalloid Solutions: Based on Tonicity

Hypertonic Salt SolutionsHypertonic Salt Solutions Na concNa concnn range from 250 – 1200 meq/L range from 250 – 1200 meq/L Rapid volume expansion after infusion of Rapid volume expansion after infusion of

small amounts (e.g. 250 mL)small amounts (e.g. 250 mL) tt½: similar to isotonic saline½: similar to isotonic saline may cause hemolysis at point of injectionmay cause hemolysis at point of injection

Glucose containing solutionsGlucose containing solutions

Glucose—given intravenously—is rapidly

metabolized, leaving free water behind

distributes across all compartments rapidly

CrystalloidsCrystalloids

AdvantagesAdvantages InexpensiveInexpensive Very low incidence of adverse reactionsVery low incidence of adverse reactions

DisadvantagesDisadvantages Short lived hemodynamic improvement Short lived hemodynamic improvement

(intravascular t(intravascular t½: 20 – 30 mins.)½: 20 – 30 mins.) Peripheral/pulmonary edemaPeripheral/pulmonary edema

Final Word on CrystalloidsFinal Word on Crystalloids

What is the best crystalloid?What is the best crystalloid?

Isotonic crystalloids are preferred Isotonic crystalloids are preferred over hypotonic crystalloidsover hypotonic crystalloids

Do we have to routinely give glucose Do we have to routinely give glucose containing solutions?containing solutions?

Routine dextrose administration is no longer Routine dextrose administration is no longer advised for otherwise healthy children receiving advised for otherwise healthy children receiving anesthesia.anesthesia.

There is a growing consensus to selectively There is a growing consensus to selectively administer intraoperative dextrose only in pts at administer intraoperative dextrose only in pts at greatest risk for hypoglycemia and in such greatest risk for hypoglycemia and in such situations to consider the use of fluids with lower situations to consider the use of fluids with lower dextrose concentrations (1% or 2.5%)dextrose concentrations (1% or 2.5%)

ColloidsColloids

contains high MW substances - proteins, contains high MW substances - proteins, large glucose polymerslarge glucose polymers

maintain plasma oncotic pressuremaintain plasma oncotic pressure

intravascular tintravascular t½: 3 – 6 hrs.½: 3 – 6 hrs.

Colloids: ClassificationColloids: Classification

Natural Protein ColloidNatural Protein Colloid Albumin or Plasma Protein fractionAlbumin or Plasma Protein fraction

Synthetic Protein ColloidsSynthetic Protein Colloids Hetastarch Hetastarch DextransDextrans GelatinsGelatins

AlbuminAlbumin

Colloid “gold standard”Colloid “gold standard”

Derived from human pool plasma Derived from human pool plasma → heated to 60 C for → heated to 60 C for 10 hrs → ultrafiltration10 hrs → ultrafiltration

MW: 69 kDaMW: 69 kDa

Available as: 5% and 25%Available as: 5% and 25%

Albumin 5% osmotically equivalent to an equal volume of Albumin 5% osmotically equivalent to an equal volume of plasmaplasma

AlbuminAlbumin

Use with caution in patients with Use with caution in patients with

increased intravascular permeability increased intravascular permeability

(e.g. critically ill, sepsis, trauma, burn)(e.g. critically ill, sepsis, trauma, burn)

Albumin: Side EffectAlbumin: Side Effect

RareRare

Might still have weak anticoagulation effects Might still have weak anticoagulation effects through platelet aggregation inhibition or through platelet aggregation inhibition or heparin-like effects on antithrombin IIIheparin-like effects on antithrombin III

These effects are thought to be clinically insignificant if volume replacement with albumin is kept below 25% of the patient’s blood volume.

Final word on AlbuminFinal word on Albumin

Data supporting the continued use of albumin

for general fluid resuscitation in children are

lacking and in children with traumatic brain injury, it

may actually be harmful. Its utility may exist in

specific subgroups such as neonates and patients

undergoing cardiac surgery.

HetastarchHetastarch

modified natural polysaccharidesmodified natural polysaccharides

Amylopectin Hetastarch

HetastarchHetastarch

Described in terms of:Described in terms of:

1.1. ConcentrationConcentration

2.2. Average mean MWAverage mean MW

3.3. Molar substitutionMolar substitution

4.4. CC22:C:C66 ratio ratio

Hetastarch: ConcentrationHetastarch: Concentration

Definition – grams in 100 mlDefinition – grams in 100 ml

Available as: 3%, 6% and 10%Available as: 3%, 6% and 10%

Hetastarch: average mean MWHetastarch: average mean MW

1.1. LowLow - <70 kDa- <70 kDa

2.2. Medium Medium - 130 – 270 kDa- 130 – 270 kDa

3.3. HighHigh - >450 kDa- >450 kDa

higher MW higher MW ⇒ longer volume effect⇒ longer volume effect

⇒ ⇒ greater side effectgreater side effect

Hetastarch: Molar SubstitutionHetastarch: Molar Substitution

Definition: CHDefinition: CH33CHCH22OH : glucose unitsOH : glucose units

Low (0.4 – 0.5)Low (0.4 – 0.5) High (0.62 – 0.7)High (0.62 – 0.7)

higher MS higher MS ⇒ longer volume effect⇒ longer volume effect ⇒ ⇒ greater side effectgreater side effect

Hetastarch: CHetastarch: C22:C:C66 ratio ratio

Hydroxyethyl group attached at CHydroxyethyl group attached at C2 2 hinder hinder

breakdownbreakdown

Higher ratio of CC22:C:C66 ⇒ in slower enzymatic degradation and prolonged action without increasing side effects.

HES Solutions Properties and AvailabilityHES HES 450/0.7450/0.7

HES 670/0.7

HES 130/0.4

HES 70/0.5

Trade NameTrade Name Hespan®Hespan® HextendHextend®®

Voluven ®Voluven ®

AvailabilityAvailability Europe/USEurope/US USUS Europe/USEurope/US USUS

ConcConcnn 66 66 66 66

Volume effect (h)Volume effect (h) 5 – 65 – 6 5 – 65 – 6 2 – 32 – 3 1 – 21 – 2

MWMW 450450 670670 130130 7070

MSMS 0.70.7 0.750.75 0.40.4 0.50.5

C2:C6 ratioC2:C6 ratio 4:14:1 4:14:1 9:19:1 4:14:1

HES: Unwanted Side EffectsHES: Unwanted Side Effects

Hypocoagulable effectHypocoagulable effect - - seems to interfere with the function of vWF, factor VIIIseems to interfere with the function of vWF, factor VIII and plateletsand platelets

Renal toxicityRenal toxicity - - induce renal tubular cell swelling & create hyperviscousinduce renal tubular cell swelling & create hyperviscous urineurine

PruritusPruritus - - accumulation on HES molecules under the skinaccumulation on HES molecules under the skin

VoluvenVoluven Pediatric dose: mean dose of 16 Pediatric dose: mean dose of 16 ++ 9 ml/kg 9 ml/kg

Contraindication:Contraindication:

known hypersensitivity to HESknown hypersensitivity to HES

CHF or pulmonary edemaCHF or pulmonary edema

renal failure with oliguria not related to hypovolemiarenal failure with oliguria not related to hypovolemia

pts receiving dialysis treatmentpts receiving dialysis treatment

severe hyperNasevere hyperNa++ or hyperCl or hyperCl++

intracranial bleedingintracranial bleeding

Final word on HetastarchFinal word on Hetastarch

There are still limited clinical trials in There are still limited clinical trials in children.children.

It appears that the new generation HES It appears that the new generation HES are much safer in comparison to the older are much safer in comparison to the older generation HES.generation HES.

GelatinsGelatins

polypeptides produced by degradation of polypeptides produced by degradation of bovine collagenbovine collagen

ave MW: 30,000 – 35,000 kDaave MW: 30,000 – 35,000 kDa

requires repeated infusions requires repeated infusions

no dose limitationno dose limitation

Gelofusine: Pharmaceuticals CharacteristicsGelofusine: Pharmaceuticals Characteristics

ConcentrationConcentration 4%4%

NaNa 154154

ClCl 120120

pHpH 7.47.4

Volume effectVolume effect 100%100%

Duration of vol expansionDuration of vol expansion 4 hrs4 hrs

Final word on GelofusineFinal word on Gelofusine

It has less anaphylactoid and coagulation It has less anaphylactoid and coagulation effect in comparison to HES.effect in comparison to HES.

The data supporting use of gelatin in The data supporting use of gelatin in children are limited.children are limited.

ColloidsColloids

AdvantagesAdvantages Smaller infused Smaller infused

volumevolume

Prolonged increase in Prolonged increase in plasma volumeplasma volume

Minimal peripheral Minimal peripheral edemaedema

DisadvantagesDisadvantages ExpensiveExpensive

CoagulopathyCoagulopathy

Pulmonary edemaPulmonary edema

Anaphylactoid Anaphylactoid reactionsreactions

Perioperative Fluid TherapyPerioperative Fluid Therapy

Vol of fluid = maintenance fluid requirement Vol of fluid = maintenance fluid requirement

+ deficit + loss+ deficit + loss

Estimating Maintenance Fluid RequirementsEstimating Maintenance Fluid Requirements

0 – 10 kg 4 ml/kg/hr0 – 10 kg 4 ml/kg/hr 11 – 20 kg Add 2 ml/kg/hr11 – 20 kg Add 2 ml/kg/hr > 20 kg Add 1 ml/kg/hr> 20 kg Add 1 ml/kg/hr

Preexisting DeficitsPreexisting Deficits

Overnight fastingOvernight fasting Preoperative bleedingPreoperative bleeding VomitingVomiting DiuresisDiuresis DiarrheaDiarrhea Other insensible lossesOther insensible losses

Surgical Fluid LossesSurgical Fluid Losses

Blood lossBlood loss

Third space lossThird space loss

EvaporationEvaporation

Redistribution and Evaporative Redistribution and Evaporative Surgical Fluid LossesSurgical Fluid Losses

DEGREE OF TISSUE TRAUMA ADD’L FLUID REQUIREMENTDEGREE OF TISSUE TRAUMA ADD’L FLUID REQUIREMENT

MinimalMinimal 0 - 2 ml/kg/hr 0 - 2 ml/kg/hr

Moderate 2 - 4 ml/kg/hrModerate 2 - 4 ml/kg/hr

Severe 4 - 8 ml/kg/hrSevere 4 - 8 ml/kg/hr

Blood Product TransfusionBlood Product Transfusion

What?What?

When?When?

How much?How much?

Transfusion: pRBCTransfusion: pRBC

MABL of 10-20 % EBVMABL of 10-20 % EBV MABL = MABL = EBV (pt initial Hct – lowest acceptable Hct)EBV (pt initial Hct – lowest acceptable Hct)

pt initial Hctpt initial Hct

Hb: 7- 10 g/dlHb: 7- 10 g/dl Hct: 21-30 %Hct: 21-30 % Higher target Hct for certain ptsHigher target Hct for certain pts

Blood VolumesBlood Volumes

Preterm 100 ml/kgPreterm 100 ml/kg Term 90 ml/kgTerm 90 ml/kg Infant 80 ml/kgInfant 80 ml/kg School Age 75 ml/kgSchool Age 75 ml/kg Adult 70 ml/kgAdult 70 ml/kg

Source: A Practice of Anesthesia for Infants and Children by Cote 4th ed

ProblemProblem

A 10 yr old 25 kg girl is scheduled to undergo closure of A 10 yr old 25 kg girl is scheduled to undergo closure of

colostomy. Her baseline Hct is 36% and lowest acceptablecolostomy. Her baseline Hct is 36% and lowest acceptable

Hct is 21%. What is her MABL?Hct is 21%. What is her MABL?

MABL = 1750 x MABL = 1750 x (36 – 21)(36 – 21)

3636

= 730 ml= 730 ml

ProblemProblem In the same pt, if the blood loss exceeded the MABL by In the same pt, if the blood loss exceeded the MABL by

150 ml and the target Hct is 30%, how much pRBC will 150 ml and the target Hct is 30%, how much pRBC will you give?you give?

Vol of pRBC = Vol of pRBC = (vol of blood to replace) (target Hct)(vol of blood to replace) (target Hct) Hct of blood productHct of blood product = = (150) (0.3)(150) (0.3) 0.70.7 = 64.28 = 64.28 ≈ 65 ml≈ 65 ml

Short cut: ≈ 0.5 ml of pRBC for every ml of blood Short cut: ≈ 0.5 ml of pRBC for every ml of blood loss loss

beyond the MABL if target Hct is 0.3beyond the MABL if target Hct is 0.3

Transfusion: FFPTransfusion: FFP

Indication:Indication: treatment of isolated factor deficiencies, treatment of isolated factor deficiencies,

reversal of warfarin therapy, reversal of warfarin therapy, correction of liver disease associated coagulopathycorrection of liver disease associated coagulopathy

Initial therapeutic dose: 10–15 mL/kgInitial therapeutic dose: 10–15 mL/kg

Goal: 30% of the normal coagulation factor Goal: 30% of the normal coagulation factor concentrationconcentration

Transfusion: PlateletsTransfusion: Platelets

Indication:Indication:

pts with thrombocytopenia or dysfunctional pts with thrombocytopenia or dysfunctional platelets in the presence of bleedingplatelets in the presence of bleeding

Transfusion threshold:Transfusion threshold:

Plt counts less than 50,000 x 10Plt counts less than 50,000 x 1099/L /L

THANK YOUTHANK YOU