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. 2025 Jul 8;15(1):91.
doi: 10.1186/s13613-025-01494-4.

Platelet transfusion practice in the intensive care unit: the Nine-I international platelet transfusion survey

Lene Russell  1   2   3 , Elie Azoulay  4 , Carl Thomas Anthon  5 , Frédéric Pène  6 , Padmastuti Akella  7 , Asma Mabrouki  4 , Kathryn Puxty  8 , Lene Bjerregaard Nielsen  9 , Jo Bønding Andreasen  10 , Thomas Kander  11   12 , Fredrik Sjövall  11   12 , Johanna Hästbacka  13   14 , Christine Lodberg Hvas  15   16 , Andry Van De Louw  17 , Sanjay Chawla  18   19 , Philippe R Bauer  20 , Pedro Castro  21 , Pedro Povoa  22   23   24 , Luis Coelho  22   23 , Sara Fernandez  21 , Arzu Topeli  25 , Andreas Barratt-Due  26 , Caterina Barbaglio  27 , Matthias Kochanek  28 , Ignacio Martin-Loeches  29   30 , Nancy Kentish-Barnes  4
Affiliations

Platelet transfusion practice in the intensive care unit: the Nine-I international platelet transfusion survey

Lene Russell et al. Ann Intensive Care. .

Abstract

Background: Platelet transfusions are frequent in the Intensive Care Unit (ICU), either as prophylaxis against bleeding complications or as treatment for bleeding. The European Society of Intensive Care Medicine guidelines for ICU patients generally recommend not using prophylactic platelet transfusions unless the platelet count falls below 10 × 109 cells/L in non-bleeding patients and make no recommendation for platelet transfusion threshold in non-massively bleeding patients with thrombocytopenia. Therefore, the decision to transfuse platelets is often left to clinical assessment by the treating physician. This study aims to describe current platelet transfusion preferences among ICU physicians.

Methods: An online, anonymous survey consisting of 43 items was produced in two languages (French and English) and distributed by investigators in the Nine-I research network to ICU physicians in Europe and the United States of America. The survey evaluated platelet transfusion practices in ICU patients with and without bleeding, the presence of local guidelines, and factors influencing the decisions to transfuse platelets. Only completed surveys were analysed.

Results: We received 997 surveys completed by ICU physicians. Overall, there was large heterogeneity in platelet transfusion practices between and within countries. In non-bleeding, thrombocytopenic medical ICU patients, most would transfuse prophylactic platelets at a platelet count threshold of 10 × 109 cells/L. Thirty percent would change their strategy in patients with bone marrow failure and either be more liberal (60%; 95% Confidence Limits 0.54, 0.66), more restrictive (31%; 0.26,0.36) or seek assistance. Higher thresholds were preferred in surgical patients, prior to procedures and in patients with bleeding. Only 173 (17%; 0.15,0.19) responded that they were confident about the clinical indications every time they prescribed a platelet transfusion. As for existing guidelines, only 123 (12%; 0.10,0.15) responded that they always read them. Colleagues' attitudes and departmental culture were important influencers on transfusion practice.

Conclusion: Platelet transfusion practice in the ICU is heterogeneous, both between and within countries; guidelines are often not used, and there is often uncertainty about the clinical indication.

Keywords: Critically ill; Intensive care; Platelet transfusions; Thrombocytopenia.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Participation in the survey was voluntary, and completion was regarded as informed consent; this information was given to all participants when they opened the electronic survey link. According to national legislation in the European Union and the UK, ethical permissions are not required when conducting surveys of this kind as no patient data were collected. In the USA, local IRB permission was acquired where necessary. No financial support was provided. We did not collect data on locations other than countries, so individual participants could not be traced. All collected data were anonymous and stored on a secure server owned by the Capital region of Copenhagen. Relevant permission from the Research and Innovation Department, Capital Region of Denmark, to store the data was obtained as required. Consent for publication: Not applicable. Competing interests: Dr. Kentish-Barnes’ institution received funding from the French Ministry of Health. Professor Azoulay’s institution received funding from Fisher & Paykel, MSD, Pfizer, Baxter, and Gilead, and he received funding from Gilead, Baxter, Alexion, Ablynx, and Pfizer. Professor Péne has received lecture and consulting fees from GILEAD outside of this work. Dr. Castro has received honoraria for scientific collaboration (Pfizer, MSD, Gilead, AbbVie) and advisory board (Alexion, Janssen, Sanofi, Gilead). Professor Povoa has received honoraria for lectures (Gilead, Pfizer, Mundipharma, MSD) and participation in advisory boards (Biocodex, Gilead). The rest of the authors have no competing interests.

Figures

Fig. 1
Fig. 1
Use and adherence to guidelines. A show the number of physicians who responded that they read the guidelines about platelet transfusions. Most (532, 53%; 95% CL 0.50–0.56) said they read the guidelines sometimes, and 123 (12%; 0.10,0.15) said they always read them. Alternatively, 226 (23%; 0.20,0.25) and 68 (7%; 0.05,0.09) said they rarely or never read the guidelines. In B the replies to the questions: ‘If you have read the guidelines, do you adhere to the guidelines?’ are shown. Here, the majority (591(62%; 0.59,0.65) replied that they ‘sometimes’ adhere to the guidelines, whereas 166 (17%; 0.15,0.20) said they always adhered if they had chosen to read them. The remaining 192 (20%) responded that they never or rarely adhered to the guidelines or replied that they did not know. (Please note that 48 respondents who replied ‘I do not know’ to Question A are not shown in the figure B)
Fig. 2
Fig. 2
Platelet transfusion thresholds. A Prophylactic platelet transfusion threshold in medical patients (without bleeding). B Prophylactic platelet transfusion threshold in surgical patients (without bleeding). C Platelet transfusion threshold in patients with minor bleedings (WHO I–II; not requiring RBC transfusion). D Platelet transfusion threshold in patients with MAJOR bleeding (WHO III–VI; requiring RBC transfusion)
Fig. 2
Fig. 2
Platelet transfusion thresholds. A Prophylactic platelet transfusion threshold in medical patients (without bleeding). B Prophylactic platelet transfusion threshold in surgical patients (without bleeding). C Platelet transfusion threshold in patients with minor bleedings (WHO I–II; not requiring RBC transfusion). D Platelet transfusion threshold in patients with MAJOR bleeding (WHO III–VI; requiring RBC transfusion)
Fig. 3
Fig. 3
A Conditions and treatments influencing the decision to transfuse platelets in thrombocytopenic patients without bleeding. The survey participants were asked to answer to what extent the conditions and treatments shown in the figure would influence their decision and make it more likely to transfuse. As shown in the figure, recent intracranial haemorrhage and recent major bleeding were strong influencers making it more likely for the respondents to use prophylactic platelet transfusions, whereas fever, sepsis and shock did not strongly influence the decision of most responders. DIC disseminated intravascular coagulation, ECLS extracoporeal life support, ICH intracranial haemorrhage, RRT renal replacement therapy. B Blood tests influence on the decision to transfuse platelets in thrombocytopenic patients without bleeding. The survey participants were asked to answer to what extent the biomarkers and coagulation test shown in the figure would influence their decision and make it more likely for them to transfuse. Overall, more than half of the survey respondents indicated that the viscoelastic tests TEG and ROTEM would have an influence on their decision to transfuse. APTT activated partial thromboplastin time, CRP C-reactive protein, PT Prothrombin time, INR International normalised ratio, TEG Thromboelastography, ROTEM Rotational thromboelastometry, (INR), MEA Multiple electrode aggregometry (e.g. Multiplate analyser)
Fig. 4
Fig. 4
Preferred prophylactic platelet thresholds prior to different invasive procedures in the ICU. Overall, for all procedures, the most preferred threshold was 50 × 109 cells/litre, preferred by 305 (31%) prior to placing a CVC, 346 (35%) prior to a bronchoscopy, 540 (54%) prior to a PDT and 398 (40%) prior to a lumbar puncture. More details can be found in Supplement 1, Tables and Figures S7–S10. CVC central venous catheter, PDT percutaneous dilatation tracheostomy
Fig. 5
Fig. 5
Use of coagulation tests to evaluate coagulation in thrombocytopenic patients with bleeding. Most respondents would use standard coagulation tests to evaluate coagulation in thrombocytopenic patients with bleeding. A minority said they used MEA; here 67/89(75%) and 79/118(67%) were from Denmark. (More details can be found in Supplement 1, Tables S13-14 and Figures S13-S19.). APTT activated partial thromboplastin time, CRP C-reactive protein, PT Prothrombin time, INR International normalised ratio, TEG Thromboelastography, ROTEM Rotational thromboelastometry, (INR), MEA Multiple electrode aggregometry (e.g. Multiplate analyser)
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