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Transfusion strategies in critical care

What's new

The American College of Chest Physicians (ACCP) has released a new guideline on the transfusion of fresh frozen plasma (FFP) and platelets in critically ill patients. Platelet transfusion is suggested for serious active bleeding if platelet counts are <50×10⁹/L, for stable non-bleeding patients with platelet counts <10×10⁹/L without risk of spontaneous bleeding, and for platelet counts of 30-50×10⁹/L in patients at risk of spontaneous bleeding. Platelet transfusion is also suggested for patients undergoing lumbar puncture if platelet counts are ≤40-50×10⁹/L. FFP transfusion is suggested in patients with coagulopathy undergoing bedside lumbar puncture, targeting an INR of 1.5-2. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of transfusion strategies in critical care are prepared by our editorial team based on guidelines from the American College of Chest Physicians (ACCP 2025), the Society for Cardiovascular Angiography and Interventions (SCAI/NAEMSP/AHA/ACC/ACEP 2025), the Association for the Advancement of Blood & Biotherapies (AABB 2023), the Pan-European Multidisciplinary Task Force for Advanced ...
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Diagnostic investigations

Coagulation and viscoelastic testing: as per ABC-T 2023 guidelines, initiate monitoring and measures to support coagulation immediately upon hospital admission of patients with traumatic hemorrhage.
B
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Medical management

Tranexamic acid
As per ABC-T 2023 guidelines:
Administer tranexamic acid in patients with trauma with bleeding or at risk of significant bleeding as soon as possible, if feasible, en route to the hospital and within 3 hours after injury at a loading dose of 1 g infused over 10 minutes, followed by an IV infusion of 1 g over 8 hours.
A
Do not wait for results from a viscoelastic assessment to administer tranexamic acid.
D
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Therapeutic procedures

Massive bleeding, transfusion strategies
As per ABC-T 2023 guidelines:
Insufficient evidence to recommend in favor or against using pre-hospital blood products in patients with traumatic hemorrhage.
⁄
Target hemoglobin levels of 7-9 g/dL if RBC transfusion is necessary in patients with major bleeding due to trauma.
B
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More topics in this section

  • Massive bleeding (platelet transfusion)

  • Massive bleeding (plasma transfusion)

  • Massive bleeding (coagulation factor transfusion)

  • Non-massive bleeding (RBC transfusion)

  • Non-massive bleeding (platelet transfusion)

  • Non-massive bleeding (coagulation factor transfusion)

  • Non-bleeding (RBC transfusion thresholds)

  • Non-bleeding (RBC transfusion prevention)

  • Non-bleeding (platelet transfusion)

  • Non-bleeding (plasma transfusion)

  • Non-bleeding (coagulation factor transfusion)

Specific circumstances

Pediatric patients
As per AABB 2023 guidelines:
Set a restrictive RBC transfusion threshold (< 7 g/dL) in critically ill pediatric patients and hemodynamically stable, hospitalized pediatric patients without a transfusion-dependent hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia but at risk of critical illness.
B
Consider setting transfusion thresholds in hemodynamically stable pediatric patients with congenital heart disease based on the cardiac abnormality and stage of surgical repair:
Situation
Guidance
Biventricular repair
7 g/dL
Single-ventricle palliation
9 g/dL
Uncorrected congenital heart disease
7-9 g/dL
C
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