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When to Give FFP and Platelets in Critically Ill Adults

Written by Peter Liu 

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CHEST 2025 guidelines offer platelet and fresh frozen plasma (FFP) transfusion guidance for common inpatient scenarios, but are largely based on sparse, low-quality evidence and should be applied as reference points.

Consider the 2025 CHEST Guidelines for inpatient platelet and FFP transfusions
New guidelines from CHEST offer reasonable general principles for inpatient platelet and FFP transfusions in critically ill patients:

  1. Reasonable platelet transfusion thresholds for this population include:
    1. 50 x109/L for patients with significant active bleeding
    2. 30-50 x109/L for non-bleeding patients with high risk of spontaneous bleeding
    3. 10 x109/L for all other critically ill patients
  2. For central lines and arterial lines, platelet and FFP transfusions are generally not recommended.  However, studies were underpowered and patients with platelets < 10 x109/L or INR > 3 were not included.
  3. For paracenteses and thoracenteses, platelet and FFP transfusions are generally not recommended. Evidence is minimal.
  4. For lumbar punctures, a platelet transfusion threshold of 40-50 x109/L and INR goal of 1.5-2.0 are recommended. Notably, this is more conservative than Society of Interventional Radiology guidelines.
  5. For bronchoscopy and GI endoscopy, platelet and FFP transfusions are generally not recommended. This is based on limited low-quality observational data.

Key:
Italic – Transfusion threshold not routinely recommended.  Generally, there is no clear evidence of benefit, and therefore preferable to avoid transfusion risk.
Bold – Transfusion threshold recommended.  Generally, there was evidence of worse bleeding outcomes for patients with severe thrombocytopenia and/or coagulopathy, providing indirect justification for transfusion.

How does this change my practice?
These CHEST guidelines address common considerations in inpatient medical care and provide a helpful summary of available evidence and other society guidelines on these topics. In general, the guidelines are worth reviewing and provide a good reference to consider for most inpatients, particularly those critically ill.

Source
Transfusion of Fresh Frozen Plasma and Platelets in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2025 Mar 10:S0012-3692(25)00279-X. doi: 10.1016/j.chest.2025.02.029. Epub ahead of print. PMID: 40074060

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