pediatric perioperative fluid therapy evangeline ko-villa, md, dpba clinical associate professor...
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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