Transfusion of Fresh Frozen Plasma and Platelets in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline

Abstract

Background: Platelets and fresh frozen plasma (FFP) are frequently administered to critically ill patients. Considering the variability in indications and thresholds guiding these transfusions, a comprehensive review of current evidence was conducted to provide guidance to critical care practitioners. This American College of Chest Physicians guideline examined the literature on platelet transfusions in critically ill patients with thrombocytopenia, with and without active bleeding, as well as data on prophylactic platelet and FFP transfusions for common procedures in the critical care setting.

Methods: A panel of experts developed 7 Population, Intervention, Comparator, and Outcome questions addressing platelet and FFP transfusions in critically ill patients and performed a comprehensive evidence review. The panel applied the Grading of Recommendations, Assessment, Development, and Evaluations approach to assess the certainty of evidence, and to formulate and grade recommendations. A modified Delphi technique was used to reach consensus on the recommendations.

Results: The initial search identified a total of 7,172 studies, and after the initial screening, 100 articles were reviewed. Sixteen studies met inclusion criteria, comprising 1 randomized controlled trial and 15 observational studies. Overall, the certainty of the evidence for all questions was very low. The panel formulated 7 conditional recommendations.

Conclusions: In critically ill patients with thrombocytopenia or coagulopathy, a risk/benefit assessment should be made by providers prior to transfusion of platelets or FFP. Given the known risks of blood product transfusion, and the limited data regarding the benefits from platelet or FFP transfusion, most patients will benefit from avoiding transfusion of these blood products. In patients at high risk of bleeding, or where the bleeding complication may be catastrophic, transfusion should be considered.

Keywords: arterial line; bronchoscopy; central line; critically ill; fresh frozen plasma; lumbar puncture; paracentesis; platelets; thoracentesis; transfusion.

Figure 1

Platelet transfusion thresholds in according bleeding risk and the presence of bleeding. WHO = World Health Organization.

Figure 2

Platelet and FFP transfusion thresholds for various ICU bedside procedures. The proposed strategy would be exemplified by a hypothetical critically ill patient with a platelet count of 20 × 10⁹/L who is at high risk of spontaneous bleeding and has indications for placement of a central venous catheter and performance of a thoracentesis. Recommendation 2 indicates that most practitioners would consider transfusing prophylactic platelets to this patient. When contemplating the placement of the central venous catheter, recommendation 4 would indicate that further platelet transfusions are not suggested prior to the catheter placement if the platelet level was above 30 × 10⁹/L after initial transfusion. In a similar fashion, prophylactic platelet transfusion is not suggested prior to the thoracentesis, in accordance with recommendation 6. ^aSuspected portal hypertension related bleed. FFP = fresh frozen plasma; GI = gastrointestinal; INR = international normalized ratio; LP = lumbar puncture.