Perioperative Platelet Transfusions

Aaron Stansbury Hess, M.D., Ph.D.; Jagan Ramamoorthy, M.D.; John Rider Hess, M.D., M.P.H.


Anesthesiology. 2021;134(3):471-479. 

In This Article

Prophylactic Platelet Transfusions Before Percutaneous Procedures

A normal platelet count is much higher than what is required for successful thrombin generation and maintenance of endothelial integrity at rest.[34] Based on large trials in hematological malignancies, the risk of clinically significant bleeding is modest and constant down to a platelet count of 10 × 103 cells/μl, and prophylactic platelet transfusions to prevent spontaneous bleeding are usually not necessary above a platelet count of 5 to 10 × 103 cells/μl.[9,35]

Data for prophylactic platelet transfusions before percutaneous procedures are sparse. One small trial and a few larger observational studies suggest that central lines placement by experienced providers is low-risk at platelet counts greater than or equal to 10 to 20 × 103 cells/μl.[12,36] For high-risk procedures such as liver biopsy, the Society of Interventional Radiology (Fairfax, Virginia) recommends a transfusion threshold of less than 50 × 103 cells/μl because observational studies found a slightly increased risk of bleeding below this level.[37] The AABB (formerly the American Association of Blood Banks; Bethesda, Maryland) recommends platelet transfusion before lumbar puncture for patients with a platelet count less than 50 × 103 cells/μl, and the American Society of Clinical Oncology (Alexandria, Virginia) recommends a threshold of 50 × 103 cells/μl for lumbar puncture in newly diagnosed pediatric patients with leukemia and 20 × 103 cells/μl for stable pediatric patients.[38,39]

All society guidelines regarding platelet counts before percutaneous procedures are weak recommendations based on low-quality evidence. They are also conservative: a review of 5,223 consecutive lumbar punctures in 958 children at a pediatric cancer center, including 199 children with counts less than 20 × 103 cells/μl, found an increase in the proportion of traumatic punctures, but not one serious complication.[40] A Danish cohort of 64,730 patients undergoing 83,711 lumbar punctures found that the hematoma rate was relatively constant around 0.2%, regardless of platelet count, although these results may be biased by patient selection.[41] There is no good evidence that preprocedural platelet transfusion reduces the risks of severe complications, and providers frequently fail to verify the results before starting the procedure.[42]