Platelet Transfusion Guidelines

2025 AABB and ICTMG International Clinical Practice Guidelines

GRADE Methodology 21 RCTs + 13 Observational Studies 4,867 Patients Analyzed
Decision Support Tool

Primary Reference

Metcalf RA, Nahirniak S, Guyatt G, Bathla A, White SK, Al-Riyami AZ, Jug RC, La Rocca U, Callum JL, Cohn CS, DeAnda A, DeSimone RA, Dubon A, Estcourt LJ, Filipescu …, et al. Platelet Transfusion: 2025 AABB and ICTMG International Clinical Practice Guidelines. JAMA. Published online May 29, 2025. doi:10.1001/jama.2025.7529

View Full Article
AABB (Association for the Advancement of Blood and Biotherapies) ICTMG (International Collaboration for Transfusion Medicine Guidelines)

Key Messages

Restrictive Strategies Are Safe

Evidence demonstrates that restrictive transfusion strategies probably did not cause increases in mortality or bleeding relative to liberal strategies across clinical populations.

Conserve Platelet Resources

Restrictive strategies reduce risk of adverse reactions, mitigate platelet shortages (5-7 day shelf life), and reduce healthcare costs.

Individualize Care

Consider symptoms, signs, laboratory parameters, bleeding history, medications, patient values, alternative therapies, and overall clinical context.

Avoid Unnecessary Transfusions

Platelet transfusions carry risks including septic reactions, TACO, TRALI, allergic reactions, and febrile reactions that occur more commonly than with RBC transfusions.

Good Practice Statement:

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.

Quick Reference

# Population Threshold Strength Evidence Applies To
1.1 Hypoproliferative Thrombocytopenia - Chemotherapy/Allogeneic SCT
Nonbleeding patients 		<10 × 10³/μL Strong Moderate Adults Pediatrics
1.2 Preterm Neonates - Consumptive Thrombocytopenia
Without major bleeding 		<25 × 10³/μL Strong High Neonates
1.3 Lumbar Puncture <20 × 10³/μL Strong Moderate Adults Pediatrics
1.4 Dengue - Consumptive Thrombocytopenia
Without major bleeding 		No Transfusion Strong Moderate Adults
2.1 Autologous SCT or Aplastic Anemia No Transfusion Conditional Very Low Adults
2.2 Critical Illness - Consumptive Thrombocytopenia <10 × 10³/μL Conditional Very Low Adults
2.3 Central Venous Catheter Placement
Compressible sites (IJ, femoral) 		<10 × 10³/μL Conditional Moderate Adults
2.4 Interventional Radiology Procedures <20 × 10³/μL (low-risk) or <50 × 10³/μL (high-risk) Conditional Very Low Adults
2.5 Major Non-Neuraxial Surgery <50 × 10³/μL Conditional Very Low Adults
2.6 Cardiovascular Surgery
Nonthrombocytopenic patients 		No Transfusion Conditional Very Low Adults
2.7 Intracranial Hemorrhage
Platelet count >100 × 10³/μL 		No Transfusion Conditional Low Adults

Strong Recommendations

High/Moderate Certainty Evidence
1.1 Hypoproliferative Thrombocytopenia - Chemotherapy/Allogeneic SCT

Nonbleeding patients with hypoproliferative thrombocytopenia actively receiving chemotherapy or undergoing allogeneic stem cell transplant

Transfuse when <10 × 10³/μL

Platelet transfusion should be administered when the platelet count is less than 10 × 10³/μL

Strong Recommendation Moderate Certainty

Justification: The data support no benefit with liberal strategies and a platelet count threshold <10 × 10³/μL is practical for implementation

Trials:
11
Total_Patients:
2851
Mortality_Ard:
1.8% (95% CI: -0.4% to 4.8%)
Mortality_Odds_Ratio:
1.32 (95% CI: 0.93 to 1.86)
Grade_2_4_Bleeding_Ard:
5.2% (95% CI: 0.0% to 10.5%)
1.2 Preterm Neonates - Consumptive Thrombocytopenia

Preterm neonates without major bleeding

Transfuse when <25 × 10³/μL

Platelet transfusion should be administered when the platelet count is less than 25 × 10³/μL

Strong Recommendation High Certainty

Justification: The data support no benefits with liberal policies of <50 × 10³/μL and the possibility of harm

Trials:
3
Total_Patients:
852
Mortality_Ard:
-4.5% (95% CI: -8.2% to 0.4%)
Mortality_Odds_Ratio:
0.69 (95% CI: 0.47 to 1.03)
Baseline_Mortality:
16.9%
Grade_3_4_Bleeding_Ard:
-2.7% (95% CI: -6.0% to 2.8%)
1.3 Lumbar Puncture

Patients undergoing lumbar puncture

Transfuse when <20 × 10³/μL

Platelet transfusion should be administered when the platelet count is less than 20 × 10³/μL

Strong Recommendation Moderate Certainty

Justification: A platelet count threshold <20 × 10³/μL is practical for implementation, and minimizes need for platelet transfusion, while recognizing the extremely low event rate estimate

Studies:
6
Total_Procedures:
4418
Hematoma_Rate_Plt_Under_50k:
0.78 per 1,000 procedures (95% CI: 0.00 to 10.02)
Hematoma_Rate_Plt_Under_20k:
0.00 per 1,000 procedures (95% CI: 0.00 to 2.96)
Study_Design:
Observational (non-randomized)
1.4 Dengue - Consumptive Thrombocytopenia

Patients with Dengue-related consumptive thrombocytopenia in the absence of major bleeding

No Transfusion

No platelet transfusion is recommended

Strong Recommendation Moderate Certainty

Justification: The data support no benefits with use of platelets as prophylaxis and possibility of harm

Trials:
2
Total_Patients:
453
Mortality_Ard:
-0.3% (95% CI: -0.4% to 2.5%)
Mortality_Odds_Ratio:
0.30 (95% CI: 0.01 to 7.47)
Notes:
Baseline mortality very low in both trials

Conditional Recommendations

Low/Very Low Certainty Evidence
2.1 Autologous SCT or Aplastic Anemia

Nonbleeding adult patients with hypoproliferative thrombocytopenia undergoing autologous SCT or with aplastic anemia

No Prophylaxis

A no-prophylaxis (therapeutic-only) strategy is recommended

Conditional Very Low

Justification: The evidence includes subgroup analyses of bleeding outcomes in trials. Duration of thrombocytopenia is typically short in autologous SCT. Quality of life considerations in aplastic anemia.

2.2 Critical Illness - Consumptive Thrombocytopenia

Adult patients with consumptive thrombocytopenia due to critical illness (non-Dengue) and without major bleeding

<10 × 10³/μL

Platelet transfusion should be administered when the platelet count is less than 10 × 10³/μL

Conditional Very Low

Justification: Lack of direct randomized trial data; a platelet count threshold <10 × 10³/μL is practical for implementation and minimizes requirements for platelet transfusions with attendant risks

2.3 Central Venous Catheter Placement

Adult patients undergoing CVC placement at anatomic sites amenable to manual compression (internal jugular and femoral vein)

<10 × 10³/μL

Platelet transfusion should be administered when the platelet count is less than 10 × 10³/μL

Conditional Moderate

Justification: A platelet count threshold <10 × 10³/μL is practical for implementation and minimizes need for platelet transfusion

Compressible sites refer to internal jugular and femoral vein CVC placements, as opposed to the subclavian vein which may be less amenable to manual compression
2.4 Interventional Radiology Procedures

Adult patients undergoing interventional radiology procedures

<20 × 10³/μL (low-risk) or <50 × 10³/μL (high-risk)

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 Very Low

Justification: A platelet count threshold <20 × 10³/μL or <50 × 10³/μL is practical for implementation; recognizes the varying degrees of bleeding risk by procedure

2.5 Major Non-Neuraxial Surgery

Adult patients undergoing major nonneuraxial surgery

<50 × 10³/μL

Platelet transfusion should be administered when the platelet count is less than 50 × 10³/μL

Conditional Very Low

Justification: A platelet count threshold <50 × 10³/μL is practical for implementation; recognizes the degree of potential risk of severe bleeding for these procedures

2.6 Cardiovascular Surgery

Nonthrombocytopenic patients undergoing cardiovascular surgery in the absence of major hemorrhage, including those receiving cardiopulmonary bypass

No Transfusion

No platelet transfusion is recommended

Conditional Very Low

Justification: The limited data available support no benefit with use of platelets

2.7 Intracranial Hemorrhage

Adult patients with spontaneous or traumatic, nonoperative intracranial hemorrhage with platelet count >100 × 10³/μL, including those receiving antiplatelet agents

No Transfusion

No platelet transfusion is recommended

Conditional Low

Justification: The limited data available support no benefit with use of platelets and the possibility of harm

Includes patients on antiplatelet therapy. Platelet transfusion may cause harm.

Interactive Decision Support Tool

Clinical Scenario Input
Current patient platelet count
Select a Clinical Scenario

Choose a population and enter the platelet count to receive evidence-based transfusion guidance with Bayesian probability analysis.

Transfusion-Related Adverse Events

Important: Platelet transfusions carry risks. Adverse events occur more commonly after platelet transfusion compared to red blood cell transfusion. Consider these risks when determining the need for transfusion.
Adverse Event Risk per Transfusion Severity Notes
Septic Transfusion Reaction 1/20,000 to 1/100,000 Can be life-threatening Rates may vary depending on the bacterial risk control strategy used
Transfusion-Associated Circulatory Overload (TACO) 1/100 to 1/1,000 Can cause respiratory failure More common than previously recognized
Febrile Non-Hemolytic Transfusion Reaction (FNHTR) 1/300 to 1/100 Generally self-limiting More common with platelets than RBCs
Allergic Transfusion Reaction 1/300 to 1/100 Usually mild, rarely severe Range from mild urticaria to anaphylaxis
Transfusion-Related Acute Lung Injury (TRALI) 1/12,000 to 1/190,000 Can be life-threatening Risk reduced with plasma from male-predominant donors
The rate of TACO per patient (point estimate) is 22/1,000 (NNH = 45). Septic transfusion reaction rates may vary depending on the bacterial risk control strategy used.

Overall Evidence Summary

All-Cause Mortality
High Certainty
Absolute Risk Difference
-0.4%
95% CI
95% CI: -2.2% to 1.7%
Odds Ratio
0.96 95% CI: 0.78 to 1.18

Restrictive probably results in little to no difference in all-cause mortality

WHO Grade 2-4 Bleeding
Moderate Certainty
Absolute Risk Difference
6.8%
95% CI
95% CI: 0.9% to 12.8%
Odds Ratio
1.32 95% CI: 1.04 to 1.68

Restrictive probably results in little or no difference in grade 2-4 bleeding or equivalent

WHO Grade 3-4 Bleeding
Moderate Certainty
Absolute Risk Difference
0.3%
95% CI
95% CI: -1.9% to 3.0%
Odds Ratio
1.04 95% CI: 0.76 to 1.41

Restrictive probably results in little or no difference in grade 3-4 bleeding

Minimal Important Differences (MIDs) Used

2%

Mortality difference considered clinically important

5%

Grade 3-4 bleeding difference considered clinically important

20%

Grade 2-4 bleeding difference considered clinically important

WHO Bleeding Grades Reference

Grade 0 No bleeding

No bleeding observed

None

Grade 1 Minor bleeding

Petechiae, ecchymoses, occult blood in body secretions, minor vaginal spotting

Minimal - typically does not require intervention

Grade 2 Mild blood loss

Epistaxis, hematuria, hematemesis, hemoptysis, or bleeding from other sites not requiring RBC transfusion

Moderate - may require local intervention

Grade 3 Gross blood loss

Bleeding requiring RBC transfusion (1 or more units within 24 hours)

Significant - requires RBC transfusion support

Grade 4 Debilitating blood loss

Retinal or cerebral bleeding with vision or neurological impairment, or fatal bleeding

Life-threatening - may result in permanent disability or death

Educational Use Only

This tool is designed to help navigate the 2025 AABB/ICTMG platelet transfusion guidelines and is for educational purposes only. It should not replace clinical judgment or institutional policies.

Important: Recommendations may not apply to all individual patient scenarios. Always consider the overall clinical context, patient values and preferences, and alternative therapies when making transfusion decisions.