Haematology, coagulation and transfusion

ICU thrombocytopenia and viscoelastic testing

Reviewed Nov 2026·5 references
New· views rounded down, updated weekly

Systematic approach to low platelets in ICU and how to read TEG/ROTEM to target fibrinogen, plasma, platelets and antifibrinolytics.

Definition
Thrombocytopenia (< 150 × 10⁹/L) affects 20-40% of ICU patients and independently predicts mortality. Viscoelastic tests (TEG, ROTEM) measure whole-blood clot formation, strength and lysis in 10-30 min.

At the bedside

  1. 1

    Confirm

    Exclude pseudothrombocytopenia (EDTA clumping): repeat in citrate tube, check smear.

  2. 2

    Find the cause

    Sepsis/DIC, dilution/massive transfusion, drugs (linezolid, vancomycin, piperacillin, valproate, heparin), HIT, TTP/TMA, liver disease/hypersplenism, ECMO/IABP/CRRT, marrow failure, tropical infections (dengue, malaria, leptospirosis, scrub typhus).

  3. 3

    Transfusion thresholds

    Prophylactic < 10; < 20 for CVC; < 50 for LP/major surgery/active bleeding; < 100 for neurosurgery/ICH.

  4. 4

    Viscoelastic-guided bleeding management

    Use TEG/ROTEM algorithms to target therapy rather than empirical ratios once initial resuscitation underway.

  5. 5

    Read the trace

    Prolonged clotting time (R/CT): factor deficiency → plasma or PCC. Low clot amplitude with low FIBTEM/functional fibrinogen: fibrinogen (cryo/concentrate). Low amplitude with normal FIBTEM: platelets. Increased lysis (LY30/ML > 15%): tranexamic acid.

  6. 6

    Heparin effect

    ROTEM INTEM vs HEPTEM (or TEG with heparinase) identifies residual heparin → protamine.

Bleeding with low count/function

Platelet concentrate

IV
Dose
1 apheresis unit or 4-6 random-donor units

Low fibrinogen on FIBTEM/lab

Cryoprecipitate

IV
Dose
1 unit/10 kg
Target
Fibrinogen ≥ 150-200 mg/dL in bleeding
Worked example
70 kg: 7-10 units

Hyperfibrinolysis

Tranexamic acid

IV
Dose
1 g over 10 min

ROTEM/TEG-guided therapy (typical triggers)

FindingMeaningTreatment
EXTEM CT > 80 s / TEG R prolongedCoagulation factor deficiencyFFP 15 mL/kg or PCC
FIBTEM A5 < 8-10 mm / low TEG functional fibrinogenLow fibrinogenCryoprecipitate or fibrinogen concentrate
EXTEM A5 < 35 mm with normal FIBTEM / TEG MA lowPlatelet deficitPlatelets
ML > 15% / LY30 > 3-8%HyperfibrinolysisTranexamic acid
INTEM CT long, HEPTEM normalHeparin effectProtamine

Thresholds differ between devices and algorithms; use your unit's validated algorithm.

Red flag · call your senior now
Platelets falling > 50% after day 5 on heparin, or with haemolysis: think HIT or TTP.
Pitfall
Treating pseudothrombocytopenia.
Pitfall
Using one universal ROTEM threshold across different devices.
Pearl
Linezolid-associated thrombocytopenia is common after 10-14 days, especially with renal impairment.

References

  1. 1

    Kietaibl S, Ahmed A, Afshari A, et al. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: second update 2022. Eur J Anaesthesiol 2023;40:226-304.

  2. 2

    Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2015;162:205-13.

  3. 3

    Cuker A, Arepally GM, Chong BH, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv 2018;2:3360-92.

  4. 4

    Zheng XL, Vesely SK, Cataland SR, et al. ISTH guidelines for treatment of thrombotic thrombocytopenic purpura. J Thromb Haemost 2020;18:2496-502.

  5. 5

    Farkas J. The Internet Book of Critical Care (IBCC). EMCrit Project; continuously updated.

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