Dr Simon Oczkowski, assistant professor in the Department of Medicine at McMaster University, expert in critical care medicine, and author of transfusion clinical practice guidelines, talks with Dr Roman Jaeschke about the new European Society of Intensive Care Medicine (ESICM) guidelines on transfusions in the critically ill.
ReferencesVlaar AP, Oczkowski S, de Bruin S, et al. Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2020 Jan 7. doi: 10.1007/s00134-019-05884-8. [Epub ahead of print] PubMed PMID: 31912207.
This transcript has been edited to include additional commentary on the issue of platelet transfusions for platelet counts between 10 × 109/L and 50 × 109/L.
For part 1 of this interview, click here.
Roman Jaeschke, MD: Let’s switch gears for a moment and talk about coagulopathies, starting from platelets. Any thresholds that should be kept in mind?
Simon Oczkowski, MHSc, MSc, MD: In general for platelet transfusions, similarly to red blood cell transfusions, we’ve had a trend towards reducing the amount of platelets that are transfused on a regular basis.
Unfortunately there’s very little evidence in critically ill patients, even though many of the people we care for actually have thrombocytopenia, to guide us with regard to at what level we should be transfusing platelets. Most of the literature that we used was derived from the hematologic malignancy population. Those are patients who routinely have very severe thrombocytopenias and require substantial transfusion support. That being said, we did recognize that platelets have a special role in the intensive care unit (ICU) because of the volume of procedures that we do and there was some guidance needed in that area.
For patients who are not bleeding actively, we suggested a transfusion threshold of 10 × 109/L. For prophylactic platelet procedures that were low risk of bleeding—so these were nonneurosurgical procedures, like tracheostomy, percutaneous endoscopic gastrostomy (PEG), central line—we suggested not transfusing as long as platelets were between 50 × 109/L and 100 × 109/L. For neurosurgical procedures—like lumbar puncture—we suggested transfusing to keep platelets above 100 × 109/L. These thresholds are also consistent with perioperative transfusion guidelines.
Of note, there is virtually no evidence for platelet transfusion between 10 × 109/L and 50 × 109/L and we were unable to confidently make a recommendation in this range for any procedures. Clinicians will have to consider the technical difficulty, operator skill, risks if hemorrhage were to occur, and other bleeding risks (eg, coagulopathy or use of antiplatelet drugs) when deciding whether to transfuse in this range. It may be safe to not transfuse platelets in this range for common ICU procedures; we just don’t know for sure, and it would be reasonable for clinical practice to vary.
Roman Jaeschke: So a threshold of 10 × 109/L is used prophylactically when you’re doing procedures; up to 50 × 109/L, or more, if you’re doing very invasive procedures; and 100 × 109/L for neurosurgical procedures.
You’ve had all these discussions. Let’s say that you have a patient who needs lumbar puncture, paracentesis, or thoracentesis and has an elevated international normalized ratio (INR) of 1.5 or 2.0. What would your guidelines suggest in this situation?
Simon Oczkowski: In critically ill patients who had a coagulopathy and are not bleeding, we suggested not giving prophylactic plasma products to prevent bleeding. This was a conditional recommendation.
We noted that in some patients who have, for instance, vitamin K overdose or at least signs of very high risk of bleeding—if they’re not bleeding right now—there may be indications where plasma transfusion would be warranted. However, for invasive bedside procedures, like those we usually do in the ICU—central line, tracheostomy, thoracentesis, paracentesis—we suggested against giving prophylactic plasma.
That being said, as a conditional recommendation the panel also recognized that there may be times when even a small amount of bleeding could potentially be devastating to the patient or when clinicians lack experience or skill in conducting a procedure that must be done emergently. In those cases giving plasma may be reasonable.
We also noted that the evidence supporting [the notion] that plasma transfusion would reduce the risk, duration, or complications of bleeding was very low. So to some extent correcting mild coagulopathies in the ICU might be treating the clinician more than it’s treating the patient. But sometimes that itself may be a worthwhile goal.
Roman Jaeschke: It may be important. I’m glad that you said so.