Special Communication
May 29, 2025
Platelet Transfusion2025 AABB and ICTMG International Clinical Practice Guidelines
Ryan A. Metcalf, Susan Nahirniak, Gordon Guyatt, et al
JAMA. Published online May 29, 2025. doi:10.1001/jama.2025.7529
Importance Platelet transfusion is a frequent procedure with benefits and risks.
Objective To provide recommendations in adult and pediatric populations in whom platelet transfusions are commonly performed.
Evidence Review Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology was applied to findings from 21 randomized trials and 13 observational studies in contexts of limited randomized clinical trial data. Transfusion strategies using fewer (restrictive) vs greater (liberal) amounts of platelets were compared.
Findings Evidence demonstrated that restrictive transfusion strategies probably did not cause increases in mortality or bleeding relative to liberal strategies across predefined clinical populations. Exceedingly low incidence of spinal hematoma was identified in patients with thrombocytopenia undergoing lumbar puncture. Because definitions of restrictive strategies varied across trials, recommendations reflect practical guidance. The following recommendations are strong recommendations with high/moderate–certainty evidence. For hypoproliferative thrombocytopenia in nonbleeding patients receiving chemotherapy or undergoing allogeneic stem cell transplant, platelet transfusion is recommended when platelet count is less than 10 × 103/μL. For consumptive thrombocytopenia in neonates without major bleeding, platelet transfusion is recommended when platelet count is less than 25 × 103/μL. In patients undergoing lumbar puncture, platelet transfusion is recommended when platelet count is less than 20 × 103/μL. In patients with consumptive thrombocytopenia due to Dengue without major bleeding, platelet transfusion is not recommended. The following recommendations are conditional recommendations with low/very low–certainty evidence. For hypoproliferative thrombocytopenia in nonbleeding adults undergoing autologous stem cell transplant or with aplastic anemia, prophylactic platelet transfusion is not recommended. In adults with consumptive thrombocytopenia without major bleeding, platelet transfusion is recommended when platelet count is less than 10 × 103/μL. In adults undergoing central venous catheter placement in compressible anatomic sites, platelet transfusion is recommended when platelet count is less than 10 × 103/μL. In adults undergoing interventional radiology, platelet transfusion is recommended when platelet count is less than 20 × 103/μL for low-risk procedures and less than 50 × 103/μL for high-risk procedures. For adults undergoing major nonneuraxial surgery, platelet transfusion is recommended when platelet count is less than 50 × 103/μL. For patients without thrombocytopenia undergoing cardiovascular surgery in the absence of major hemorrhage, including those receiving cardiopulmonary bypass, platelet transfusion is not recommended. For nonoperative intracranial hemorrhage in adults with platelet count greater than 100 × 103/μL, including those receiving antiplatelet agents, platelet transfusion is not recommended.
Conclusions And Relevance A consistent pattern of evidence supports the implementation of restrictive platelet transfusion strategies. Restrictive strategies reduce risk of adverse reactions, mitigate platelet shortages, and reduce costs. It is good practice to consider overall clinical context and alternative therapies in the decision to perform platelet transfusion.
Strong Recommendations (1.1-1.4)
The panel strongly recommends restrictive over liberal platelet transfusion strategies based on high- or moderate-certainty evidence in the 4 populations defined below. Table 2 provides the summary of findings and Table 3 summarizes all recommendations.
Recommendation 1.1: in nonbleeding patients with hypoproliferative thrombocytopenia actively receiving chemotherapy or undergoing allogeneic stem cell transplant, platelet transfusion should be administered when the platelet count is less than 10 × 103/μL (strong recommendation, moderate-certainty evidence).
Recommendation 1.2: in preterm neonates without major bleeding, platelet transfusion should be administered when the platelet count is less than 25 × 103/μL (strong recommendation, high-certainty evidence).
Recommendation 1.3: in patients undergoing lumbar puncture, platelet transfusion should be administered when the platelet count is less than 20 × 103/μL (strong recommendation, moderate-certainty evidence).
Recommendation 1.4: in patients with Dengue-related consumptive thrombocytopenia in the absence of major bleeding, the panel recommends no platelet transfusion (strong recommendation, moderate-certainty evidence).
Conditional Recommendations (2.1-2.7)
In the predefined clinical populations mentioned below, certainty of evidence was low or very low, with the exception of CVC placement at compressible anatomic sites (moderate certainty for grade 2-4 bleeding; very low certainty for grade 3-4 bleeding). The panel made conditional recommendations in favor of restrictive over liberal platelet transfusion.
Recommendation 2.1: in nonbleeding adult patients with hypoproliferative thrombocytopenia undergoing autologous SCT or with aplastic anemia, the panel recommends a no-prophylaxis strategy (conditional recommendation; low- to very low–certainty evidence).
Recommendation 2.2: in adult patients with consumptive thrombocytopenia due to critical illness (non-Dengue) and without major bleeding, platelet transfusion should be administered when the platelet count is less than 10 × 103/μL (conditional recommendation; very low–certainty evidence).
Recommendation 2.3: in adult patients undergoing CVC placement at anatomic sites amenable to manual compression, platelet transfusion should be administered when the platelet count is less than 10 × 103/μL (conditional recommendation; moderate- to very low–certainty evidence).
Recommendation 2.4: in adult patients undergoing interventional radiology procedures, platelet transfusion should be administered when the platelet count is less than 20 × 103/μL for low-risk procedures and less than 50 × 103/μL for high-risk procedures (conditional recommendation; very low–certainty evidence).
Recommendation 2.5: in adult patients undergoing major nonneuraxial surgery, platelet transfusion should be administered when the platelet count is less than 50 × 103/μL (conditional recommendation; very low–certainty evidence).
Recommendation 2.6: in nonthrombocytopenic patients undergoing cardiovascular surgery in the absence of major hemorrhage, including those undergoing cardiopulmonary bypass, the panel recommends no platelet transfusion (conditional recommendation; very low—certainty evidence).
Recommendation 2.7: in adult patients with spontaneous or traumatic, nonoperative intracranial hemorrhage when the platelet count is greater than 100 × 103/μL, including for those receiving antiplatelet agents, the panel recommends no platelet transfusion (conditional recommendation; low- to very low–certainty evidence).
The panel considered it good clinical practice to also consider symptoms, signs, other laboratory parameters, bleeding history, medications, patients’ values and preferences, alternative therapies, and overall clinical context when deciding to perform a platelet transfusion on a particular patient. It is possible that this recommendation, although not intended for legal proceedings but rather as a guide for patient care, may reassure clinicians contemplating not administering unnecessary platelet transfusions whose behavior may be influenced by worries about litigation.
