AABB guidelines for prophylactic platelet transfusions

1. The AABB strongly recommends transfusing hospitalized adult patients with therapy induced hypoproliferative thrombocytopenia and a platelet count of 10×10⁹ cells/L or less.

2. The AABB weakly recommends prophylactic transfusion for patients with a platelet count of less than 20×10⁹ cells/L undergoing elective central venous catheter placement and less than 50×10⁹ cells/L undergoing elective diagnostic lumbar puncture or major non-neuraxial surgery.

3. The AABB recommends against routine prophylactic platelet transfusion for patients who are non-thrombocytopenic and have cardiac surgery with cardiopulmonary bypass.

Evidence Rating Level: 2 (Good)

Study Rundown: To update clinical practice guidelines for platelet transfusions, the American Association of Blood Banks (AABB) conducted a systematic review of randomized, clinical trials (RCTs) and observational studies looking at clinical outcomes and number of platelet units transfused. Based on this review, the following recommendations were made. (1) Because platelet prophylaxis reduces, but does not eliminate, bleeding risk in patients with therapy-induced (i.e., radiation or chemotherapy) hypo-proliferative thrombocytopenia, they recommend prophylactic transfusion for platelets at 10×10⁹ cells/L or less. Studies did not show added benefit for high-dose platelet therapy as compared to low-dose therapy when treating therapy-induced thrombocytopenia. (2) For elective central venous catheter placement, the AABB suggests prophylactic transfusion for platelets less than 20×10⁹ cells/L, although serious bleeding complications are rare. (3) The AABB suggests prophylactic transfusion for both elective diagnostic lumbar puncture and for non-neuraxial surgery in those with platelets less than 50×10⁹ cells/L. (4) Unless there is evidence of peri-operative bleeding with thrombocytopenia and/or platelet dysfunction, the AABB recommends against prophylactic platelet transfusion for patients who are non-thrombocytopenic and have cardiac surgery with cardiopulmonary bypass. (5) The AABB does not recommend for or against platelet transfusion for patients with intracranial hemorrhage and on antiplatelet therapy. These recommendations are limited primarily by the reviewed studies, of which some were observational or specialized, limiting the generalizability of these guidelines.

Click to read the study, published today in the Annals of Internal Medicine

In-Depth [systematic review]: From review of RCTs and observational studies, prophylactic platelet transfusion in therapy-induced hypoproliferative thrombocytopenia was found to decrease risk for spontaneous bleeding (OR 0.53; 95%CI 0.32-0.87). Platelet counts of 20×10⁹ cells/L and 30×10⁹ cells/L were not associated with significantly lower incidence of bleeding (OR 0.74; 95%CI 0.41-1.35), or bleeding-related mortality (OR 0.37; 95%CI 0.02-9.22) in patients with radiation or chemotherapy thrombocytopenia. Additionally, no difference in bleeding between low-dose platelets vs. standard-dose (OR 0.91; 95%CI 0.70-1.19), and low-dose vs. high-dose platelets (OR 1.05; 95%CI, 0.79-1.40) was identified. Observational studies revealed increased risk of bleeding during central venous catheter placement in patients with platelets less than 20×10⁹ cells/L. Data from observational studies failed to demonstrate increased risk of bleeding during lumbar puncture in patients with platelets of 50×10⁹ cells/L or less. In a series of patients with leukemia and pre-operative platelet count below 50×10⁹ cells/L, patients received prophylactic platelets and resulted with median post-operative levels of 56×10⁹ cells/L and only 7% of cases experienced >500 mL blood loss. In a meta-analysis of cardiac surgical cases, platelet transfusion was identified as a marker for adverse outcomes, and observational studies demonstrated mixed outcomes for platelet transfusion in traumatic injury.

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