Practice Variation for Platelet Transfusion in Patients with Severe Refractory Thrombocytopenia: A Survey of Critical Care Practitioners

Abstract

Background

Severe thrombocytopenia refractory to platelet transfusion is an increasingly common issue and poses challenges for safely performing procedures in the intensive care unit (ICU).

Objective

To describe platelet transfusion thresholds and strategies ICU clinicians use when performing invasive procedures with general low bleeding risk in patients with severe refractory thrombocytopenia (below 5000/mm³), a scenario for which no current guideline recommendations exist.

Design

Cross-sectional web-based survey of ICU clinicians in adult oncologic ICU

Results

Of 110 ICU clinicians 65 (59%) completed the survey (median IQR age: 36 years (31-43), 63% female). For placing a central venous catheter (CVC) majority (60%) chose a platelet transfusion threshold <20 000/mm³, while 40% chose a threshold ≥20 000/mm³. Lower thresholds were used frequently by Fellows, APPs, and clinicians with ≤5 years experience in ICU or < 50 CVC placements experience, whereas CCM attendings and more experienced clinicians favored higher thresholds (P = .015). Majority (74%) transfused one unit of platelets while performing the procedure under ultrasound guidance. The internal jugular vein was the preferred site (63%). Similar strategies and platelet thresholds were employed for hemodyalisis catheter (HD) placement. Desmopressin was administered by 55% before HD catheter placement. Thirty-seven percent reported patients with platelet counts below 20 000/mm³ undergoing line placement never required post-procedure transfusion for bleeding.

Conclusions

The survey shows that ICU clinicians are safely and comfortably performing procedures at platelet thresholds below 20,000, revealing a gap between guideline recommendations and real-world practice and a need for additional evidence to guide invasive procedures in this population.