The Real-World Boards: Question #4
A thrombocytopenic patient needs a central line. To transfuse or not, and when
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Your patient in bed 14 is receiving increasing doses of norepinephrine for presumed sepsis, and a central venous catheter is indicated. Her last dose of apixaban for atrial fibrillation was two days ago. Ultrasound reveals that her internal jugular veins are suitable sites. You remember her hemoglobin was between 8 and 9 g/dL yesterday, but her platelets were low. A repeat CBC is pending.
Surprisingly little reliable data exists to guide the decision whether to transfuse platelets before minor invasive procedures.
Guideline authors recommend a restrictive approach toward prophylactic platelet transfusions before central venous catheter placement:
A critical care society’s 2025 panel advised proceeding without transfusion, even in patients with severe thrombocytopenia at high risk for bleeding. Single-digit platelet counts might justify a prophylactic transfusion, they implied (without outright recommending this).
The society governing blood stewardship and transfusion practices (AABB) recommended transfusion to platelet counts of ≥10K in a 2025 statement.
The interventional radiologists’ society advised transfusion to platelet counts of ≥20K in its 2019 guidance.
What makes the societies’ restrictive advice interesting is that although data is scarce, the only available high-quality study (which they do cite) found that prophylactic platelet transfusions before central line placement did reduce bleeding risk.