Synopsis
Choose the correct haemostatic component for thrombocytopenia, factor deficiency or hypofibrinogenaemia, apply UK thresholds and avoid ineffective or harmful prophylactic transfusion.
- Platelets treat or prevent bleeding caused by inadequate platelet number or function; plasma replaces multiple soluble coagulation factors; cryoprecipitate provides concentrated fibrinogen.
- For clinically significant non-major bleeding, NICE recommends platelet transfusion when the platelet count is below 30 × 10⁹/L.
- For severe bleeding or bleeding in a critical site, use a higher platelet threshold up to 100 × 10⁹/L according to severity and location.
- For prophylaxis in a non-bleeding patient without specified exclusions, NICE recommends platelets below 10 × 10⁹/L.
- Do not routinely give prophylactic platelets for chronic bone-marrow failure, immune thrombocytopenia, heparin-induced thrombocytopenia or thrombotic thrombocytopenic purpura.
- Before invasive procedures or surgery, raise platelets above 50 × 10⁹/L; consider 50–75 for higher bleeding risk and above 100 for surgery at critical sites such as the central nervous system or posterior eye.
- Do not routinely give prophylactic platelets for low-risk central venous cannulation or bone-marrow aspiration and trephine biopsy.
- First-line adult platelet dose is one adult therapeutic dose, followed by clinical and count reassessment before another dose unless bleeding is major.
- Consider fresh frozen plasma for clinically significant bleeding with abnormal coagulation tests, using PT or APTT ratio above 1.5 as the NICE decision point outside major haemorrhage.
- Do not use plasma simply to normalise mildly prolonged coagulation tests in a non-bleeding patient; consider it before a procedure only when bleeding risk is clinically significant.
- Consider cryoprecipitate for clinically significant bleeding when fibrinogen is below 1.5 g/L, or prophylactically before a risky procedure when it is below 1.0 g/L.
- First-line adult cryoprecipitate dose is two pools, followed by repeat fibrinogen and clinical reassessment; major or obstetric bleeding follows the local rapid-replacement protocol.
Key red flags
Bleeding into the brain, eye, airway, pericardium or another critical site warrants a higher platelet target and immediate specialist haemostasis support.
A rapidly falling platelet count with thrombosis, organ injury or microangiopathic haemolysis suggests TTP, HIT or DIC; prophylactic platelets can be inappropriate outside life-threatening bleeding.
Persistent diffuse bleeding despite component therapy may reflect uncontrolled source, hypothermia, acidosis, hypocalcaemia, hyperfibrinolysis, anticoagulant effect or profound fibrinogen depletion.
Plasma is not first-line reversal for warfarin-associated major bleeding; urgent four-factor prothrombin-complex concentrate and intravenous vitamin K are used under the anticoagulant-reversal protocol.
Dyspnoea, hypoxia, hypertension, hypotension, urticaria or fever during any component requires immediate cessation and acute-transfusion-reaction assessment.
Investigation priorities
Quantify thrombocytopenia and establish whether it is stable, recovering or being consumed.
Identify multiple-factor deficiency, consumption and hypofibrinogenaemia.
Management branches
Clinically significant bleeding occurs with thrombocytopenia.
- Assess site and severity, send count, coagulation, fibrinogen and film and treat the cause.
- If the count is below 30 × 10⁹/L, give one adult therapeutic dose; use a higher threshold up to 100 for severe or critical-site bleeding.
- Reassess bleeding and the post-dose count before another dose and investigate a poor increment.