Abstract
Institutional generation and adoption of clinical practice guidelines of platelet transfusion thresholds for lumbar puncture (LP) pose a clinical challenge. These challenges are inherent to the procedure itself as well as the interests of the respective clinical services involved. LP has morbid complications of spinal hemorrhage/hematoma, paralysis, and need for invasive procedures such as spinal decompression. In the setting of these understood risks, multidisciplinary collaboration ultimately leading to consensus in establishing clinical practice guidelines at the institutional level are challenging—mainly because there exists a large disconnect between guidelines set forth by the national associations/committees of the respective services involved. For example, the platelet transfusion threshold recommended for LP by several societies are as follows: Society of IR at 50,000 (Patel et al, 2019), American Society of Clinical Oncology at 40,000-50,000 (Schiffer et al, 2018), Advancement of Blood and Biotherapies (AABB, formerly American Association of Blood Banks) at 50,000 (Kaufman et al, 2015), and the Association of British Neurologists (Dodd et al, 2018) and British Society of Haematology (Estcourt et al, 2016) at 40,000 with individualized consideration down to 20,000.
More recently (May 29, 2025), the AABB and International Collaboration for Transfusion Medicine Guidelines (ICTMG) published international clinical practice guidelines regarding platelet transfusion thresholds and strongly recommended a threshold of 20,000 for LP based on moderate-certainty evidence (Metcalf et al, 2025). Notably, there was a paucity and/or absence of representatives from IR/Anesthesiology in the clinical committees making these recommendations. From a procedural aspect, recent correspondence (Siddiqui 2025), with writers of the American Society of Regional Anesthesia and Pain Medicine's (ASRA) new evidence-based guidelines (Kopp et al, 2025) addressing those concerning LP concluded with the advisory for anesthesiologists to follow the ASRA guidelines in the setting of elective LP, and to otherwise continue multidisciplinary collaboration on an individualized patient basis while additionally endorsing the need for continued discussion and research in these complex clinical situations (Kopp et al, 2025).
We present here a single institution experience at New York Medical College (NYMC) that highlights the need for interpretation of guidelines that include perspectives and input from proceduralists who perform specific procedures such as LP. Inclusion of these viewpoints will improve patient safety and give providers input into their own medical legal risks. Despite the approval of a quality improvement initiative (IRB protocol 21712) at NYMC in 2024, ongoing multidisciplinary collaboration (Hematology/Oncology, Neurology, Anesthesiology/IR, Transfusion Medicine), as well as the recently updated guidelines from AABB/ICTMG and ASRA, implementation of an updated clinical practice protocol remains a challenge. While there exists a significant level of nuance to this delicate clinical setting, we hope to share our institutional experience to emphasize one key point: to truly enhance patient safety and reduce legal liability, guideline authors must consider to engage directly with frontline medical staff that perform procedures and understand the clinical implications involved, thereby narrowing the great divide currently experienced in clinical practice.
