Transfusion of Fresh Frozen Plasma and Platelets in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline
Angel Coz Yataco, Israa Soghier, Paul C. Hébert, et al
Chest 2025; 168: 661-676
DOI: 10.1016/j.chest.2025.02.029
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.
Summary of Recommendations
The recommendations in this document apply to critically ill patients, excluding trauma and neuro-critical care populations. These recommendations should be implemented in a hierarchal fashion. Recommendations 1-3 should be applied first to critically ill patients with thrombocytopenia, while recommendations 4-7 provide additional guidance for specific situations involving invasive procedures.
1. In stable non-bleeding critically ill patients with thrombocytopenia and without high risk of spontaneous bleeding, we suggest transfusing platelets if platelet counts fall below 10 × 109/L (Conditional Recommendation, Very Low Certainty of Evidence).
2. In stable non-bleeding critically ill patients with thrombocytopenia who are considered at high risk of spontaneous bleeding, we suggest transfusing platelets if platelet counts fall below 30-50 × 109/L (Conditional Recommendation, Very Low Certainty of Evidence).
3. In critically ill patients with thrombocytopenia and serious active bleeding, we suggest transfusing platelets if platelet counts fall below 50 × 109/L (Conditional Recommendation, Very Low Certainty of Evidence)
4. Vascular procedures
4A. In critically ill patients at increased risk of bleeding due to thrombocytopenia undergoing a central venous catheter (CVC) or arterial line insertion, we suggest against routine prophylactic platelet transfusion (Conditional Recommendation, Very Low Certainty of Evidence).
4B. In critically ill patients at increased risk of bleeding due to coagulopathy undergoing a CVC or arterial line insertion, we suggest against routine prophylactic fresh frozen plasma (FFP) transfusion (Conditional Recommendation, Very Low Certainty of Evidence).
5. Bedside thoracic or abdominal procedure
5A. In critically ill patients with increased risk of bleeding due to thrombocytopenia undergoing a bedside thoracentesis or paracentesis, we suggest against routine prophylactic platelet transfusion (Conditional Recommendation, Very Low Certainty of Evidence).
5B. In critically ill patients with increased risk of bleeding due to coagulopathy undergoing a bedside thoracentesis or paracentesis, we suggest against routine prophylactic FFP transfusion (Conditional Recommendation, Very Low Certainty of Evidence).
6. Lumbar puncture
6A. In critically ill patients with increased risk of bleeding due to thrombocytopenia undergoing a bedside lumbar puncture, we suggest platelet transfusion if platelets counts are 40-50 × 109/L or lower (Conditional Recommendation, Very Low Certainty of Evidence).
6B. In critically ill patients with increased risk of bleeding due to coagulopathy undergoing a bedside lumbar puncture, we suggest FFP transfusion to target international normalized ratio (INR) 1.5-2 before the procedure (Conditional Recommendation, Very Low Certainty of Evidence).
7. Bedside endoscopy
Bronchoscopy
7A. In critically ill patients with increased risk of bleeding due to thrombocytopenia undergoing routine flexible bronchoscopy without biopsy, we suggest against routine prophylactic platelet transfusion (Conditional Recommendation, Very Low Certainty of Evidence).
7B. In critically ill patients with increased risk of bleeding due to coagulopathy undergoing a routine bedside flexible bronchoscopy without biopsy, we suggest against routine prophylactic FFP transfusion (Conditional Recommendation, Very Low Certainty of Evidence).
GI endoscopy
7C. In critically ill patients with suspected portal hypertension related gastrointestinal (GI) bleeding and increased risk of bleeding due to thrombocytopenia who are undergoing GI-endoscopy, we suggest against routine platelet transfusion (Conditional Recommendation, Very Low Certainty of Evidence)
7D. In critically ill patients with suspected portal hypertension related bleeding and increased risk of bleeding due to coagulopathy who are undergoing GI-endoscopy, we suggest against routine FFP transfusion (Conditional Recommendation, Very Low Certainty of Evidence)
