Guidelines in Review: CHEST Advises Against Routine Blood Transfusions for Critically Ill Patients During Procedures

Cleveland Clinic critical care and pulmonary medicine expert Angel Coz Yataco, MD, presented recent guidelines recommending against routine prophylactic blood product transfusions in critically ill patients undergoing invasive procedures including bronchoscopy, lumbar puncture, and vascular access.

The presentation of the guidelines — authored and reviewed by a panel of experts from institutions including the Cleveland Clinic, Massachusetts General Hospital, and more — emphasized individualized patient assessment and parameters including specific bleeding risks and laboratory thresholds to determine blood transfusion decisions. The recommendations were published in the CHEST journal amid the organization’s annual meeting in Chicago, IL, this week.

Though most of the recommendations were defined as conditional and based on low to very low certainty of evidence per the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) scale, the guidelines provide endorsement of strategies that buck against long-standing, albeit controversial approach of prophylactic transfusions for non-bleeding, critically ill patients.

Platelets and FFP are scarce resources with variable costs and access globally,” the authors wrote. “Therefore, judicious use is critical, preserving them for patients when the benefits outweigh the risks. The existing inconsistencies in transfusion practices underline the importance of evidence-based recommendations to optimize patient care and resource utilization.”

Key among the recommendations were the following:

• Avoid routine prophylactic platelet transfusions during bedside flexible bronchoscopy and thoracentesis in critically ill patients at increased bleeding risk, unless platelet counts fall below 40-50 x 10^9/L for lumbar puncture or 10 x 10^9/L for stable, non-active bleeding patients.
• Avoid routine fresh frozen plasma (FFP) transfusions prior to procedures including central venous catheter (CVC) insertions, arterial line placements, and endoscopies involving portal hypertension-related gastrointestinal bleeding, regardless of abnormalities in coagulation tests or international normalized ratio (INR) levels.
• Practice transfusion thresholds for patients with active bleeding or high-risk factors: platelets below 50 x 10^9/L to control active bleeding, or below 30-50 x 10^9/L for high-risk yet stable patients.

“These guidelines emphasize utilizing a tailored approach to transfusions, prioritizing patient-specific risk assessments and limiting unnecessary use of blood products in critical care settings,” Yataco said.

The conservative recommendations are also informed by significantly limited, relevant research into the benefit-risk profile of blood transfusions for critically ill invasive procedures; though Yataco and colleagues reviewed 7000-plus studies, only 16 met their inclusion criteria.

What does this mean for critical care practice?

By discouraging routine use of blood products before invasive procedures unless specific thresholds are met, the guidelines may minimize transfusion-related risks such as immune reactions, circulatory overload, and lung injury. They also seek to promote conscientious resource use amid rising healthcare costs.

Yataco and colleagues emphasized “shared decision-making and individualized assessment” from clinicians to contribute toward the goal of optimizing invasive procedure outcomes and ensured patient safety.

Despite the lack of high-certainty evidence, these guidelines provide a framework for managing critically ill patients with thrombocytopenia and coagulopathy,” the authors wrote. “Shared decision-making and the implementation of institutional guidelines to standardize transfusion practices could optimize patient care, improve equity in access to blood products and reduce costs.”

The team estimated that large-scale adoption of these recommendations could result in approximately 500,000 fewer units of platelets and FFP transfused annually. They advocated for institutions to develop local policies based on these recommendations — and to further monitor how they impact their transfusion practices.

References

1. Coz Yataco AO, Soghier I, Hébert PC, et al. Red Blood Cell Transfusion in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2025;167(2):477-489. doi:10.1016/j.chest.2024.09.016