Platelet transfusion trigger in difficult patients

There is general consensus that a prophylactic pre-transfusion trigger at 10.000 platelets/μL in stable oncohematological patients is as safe as the traditional trigger of 20.000/μL, and that perioperative triggers at 50.000 and 100.000/μL are adequate in most surgical and neurosurgical conditions respectively. Guidelines on the trigger and other issues related to platelet transfusion can be found in nine documents published during 1987-2001 by the National Institutes of Health (NIH), the British Committee on Standardization in Hematology, the Royal College of Physicians of Edinburgh, the College of American Pathologists, the American Society of Anesthesiology and the American Society of Clinical Oncology (ASCO). Although consensus may be less evident on specific triggers for 'difficult' patients, the following triggers, listed by progressively increasing levels, have been proposed in the literature and have found general agreement: a stable oncohematological recipient: 10.000; lumbar puncture in a stable pediatric leukemic patient: 10.000; heparin-induced thrombocytopenia: 10.000; bone marrow aspiration and biopsy: 20.000; gastrointestinal endoscopy in cancer: 20.000-40.000; disseminated intravascular coagulation: 20.000-50.000; fiber-optic bronchoscopy in a bone marrow transplant recipient: 20.000-50.000; neonatal alloimmune thrombocytopenia: 30.000; major surgery in leukemia: 50.000; thrombocytopenia secondary to massive transfusion: 50.000; invasive procedures in cirrhosis: 50.000; cardiopulmonary bypass: 50.000-60.000; liver biopsy: 50.000-100.000; a nonbleeding premature infant: 60.000; neurosurgery: 100.000. The proposed values must be considered within the context of careful clinical evaluation of each individual patient, and attention should be given to the power of discrimination of platelet counters at low counts and to the prompt availability of good quality platelet products in the case of emergency.