Platelet Guidelines Pivot to More Restrictive Use
Since the studies defined “restrictive” differently, the panel created practical recommendations to guide care.
Updated guidance on platelet transfusion recommends a shift toward restrictive strategies for adults and children, citing strong evidence that such practices reduce adverse reactions, alleviate supply challenges and curb unnecessary healthcare costs.
“Platelet Transfusion: 2025 AABB and ICTMG International Clinical Practice Guidelines,” in JAMA, emphasizes the importance of tailoring decisions to individual patient needs, preferences and specific care scenarios, particularly when guidance is listed as “conditional” or based on “good practice statements” rather than “strong.”
An expert panel developed the guidelines using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, informed by 21 randomized trials and 13 observational studies that compared platelet transfusion thresholds at lower (restrictive) with higher (liberal) platelet counts. The panel prioritized mortality reduction, limiting exposure and quality of life, while noting that patient values may still influence decisions.
Evidence showed that using fewer platelet transfusions didn’t lead to more deaths or bleeding in most patient groups. And because the studies defined “restrictive” differently, the panel created strong and conditional practical recommendations to guide care.
Strong recommendations for restrictive over liberal transfusion strategies include the following:
- Provide platelet transfusions to nonbleeding patients undergoing chemotherapy or stem cell transplant when the platelet count is less than 10×103/μL.
- For preterm neonates without major bleeding, transfuse platelets if the platelet count is less than 25×103/μL.
- For patients undergoing lumbar puncture, prioritize transfusion if the platelet count is below 20×103/μL.
- Avoid platelet transfusion in patients with dengue fever who are stable and not bleeding.
Key strengths of the guidelines include adherence to rigorous development standards, consistent application of GRADE methodology, broad stakeholder involvement and international relevance.
Notable limitations are the variability in bleeding risk among patients with thrombocytopenia, the presence of low-certainty evidence in some contexts, unclear baseline risks, reliance on indirect data, and the need for further implementation work to improve guideline applicability.
Nursing Team Guides Critical Care Patient’s DKA Recovery
The successful outcome was based on a collaborative, multidisciplinary team approach.
A case review involving a 34-year-old woman with diabetic ketoacidosis (DKA) and extreme hyperglycemia highlights gaps in existing protocols and shows how a coordinated, multidisciplinary effort can lead to successful resuscitation and practical insights for nursing teams.
“Emergency Nursing Care in a Patient With a Serum Blood Glucose of 2394 mg/dL: A Case Review,” in Journal of Emergency Nursing, documents the patient’s successful resuscitation in a small rural emergency department (ED) that lacked on-site intensivist or endocrinologist support. The outcome was driven by focused emergency nursing management, including airway protection, fluid resuscitation, progressive correction of plasma tonicity and osmolarity, and mitigation of life-threatening complications.
The patient arrived in the ED unresponsive and hemodynamically unstable (BP 65/48 mm Hg, RR 28) with a history of type 1 diabetes and prior foot infections with right hallux amputation. Serum analysis revealed a blood glucose of 2394 mg/dL, ketones (45.32 mg/dL), potassium (6.1 mmol/L), unmeasurable hypothermia, confirmed COVID-19 positivity and ECG with peaked T-waves that progressed to torsades de pointes.
Extreme hyperglycemia in DKA remains poorly documented, potentially due to underreporting or its clinical rarity, the review notes. Existing protocols don’t explicitly address such cases, leaving intervention guidance uncertain.
In this case, stabilization focused on emergent airway support using a bag-value-mask (BVM) and high-flow oxygen, intraosseous and ultrasound-guided IV access, and initiation of protocols for hyperkalemia and DKA. The patient received warmed fluids for hypothermia and was continuously monitored via a urinary catheter before being transferred to a tertiary care center.
The case underscores how extreme clinical presentations can challenge conventional diagnostic thresholds, requiring nuanced judgment and focused nursing care. The outcome reflects the strength of a multidisciplinary team answering the challenges of “how to treat when it’s unclear how to treat,” the review adds.
“Considering the successful survival of this patient, the effective management may inform future decision-making in extreme hyperglycemia in DKA.”
Case Study Shows Nurses’ Role in Identifying Sepsis
The case stresses the importance of action in the initial hour, which includes a six-step bundle.
Nurses in emergency and ICU settings who recognize early symptoms of sepsis can help initiate priority treatments within the first hour that can prove lifesaving.
Sepsis in the Hospital Setting: A Case Study,” in American Nurse, notes that a triage nurse identifies signs of sepsis in an emergency department patient that leads to intensive care hospitalization and the rapid onset of treatment. “Nurse knowledge of changes in the sepsis guidelines and current recommendations as well as patient education and post-discharge management help ensure appropriate care,” the article adds.
The case study includes definitions, a breakdown of risk factors and a summary of signs and symptoms of sepsis. Using guidance from the Surviving Sepsis Campaign, the case stresses the importance of action in the initial hour, which includes a six-step bundle.
The case study describes the nurses’ role in the patient’s ongoing care and progress, demonstrating how early actions produce positive results and reduce the risk of worsening outcomes, all the way to a transfer out of the ICU after three days. During ongoing monitoring of hemodynamic trends, for example, “the nurse reports them to the NP and requests an order to discontinue all catheters and I.V. devices that are no longer required and to de-escalate the antibiotics.”
AACN offers an array of clinical resources for nurses to help identify sepsis early. Featured resources include the nursing implications of the 2021 Surviving Sepsis Guidelines, strategies to overcome challenges, a clinical decision algorithm and a pediatric guide for oxygen delivery.
In addition to accessing videos and recorded sessions, nurses can earn AACN’s Sepsis Micro-Credential. “As a nurse, your crucial first assessment can make all the difference ― but you need to know the signs and when to speak up,” notes the resource page.
Dyspnea Common, Distressing for Ventilated Patients
Many interventions may be necessary, and even communication and empathy might be effective.
Dyspnea, recognized as a distressing event for mechanically ventilated patients, affects about 40% of communicative individuals at moderate to severe levels with few management strategies.
“Dyspnea Among Mechanically Ventilated Patients: A Systematic Review,” in Critical Care Medicine, which reviewed 21 observational studies and three randomized controlled trials, finds that dyspnea can result in adverse outcomes, including PTSD. The review identifies an assortment of interventions in the studies, including muscle training, ventilation adjustments, opioids, music and fan therapy. The majority of patients who are noncommunicative could not be effectively addressed, and the studies did not identify the efficacy of the interventions.
“Although growing attention has been given to the assessment and treatment of pain in the ICU, very little attention has been given to dyspnea, which remains markedly under-evaluated and under-treated, especially in mechanically ventilated patients,” adds an accompanying editorial in Critical Care Medicine. The editorial notes that because dyspnea is a symptom and not a physical sign, it is likely underreported even among patients capable of reporting it. The fear and anxiety associated with the distress of struggling to breathe should be viewed as potentially worse than pain.
Because the experience can be traumatic with reported feelings of helplessness, and one long-term study found a link to PTSD, the editorial suggests patients might be caught in a cycle of unpredictability and powerlessness. “The uncontrollable nature of breathlessness and its association with PTSD reminds the studies of torture survivors, which have shown that asphyxiation was the most important predictor of PTSD symptoms.”
The editorial adds that multiple interventions might be necessary, and even communication and empathy might be effective. “Any attempt to bring light on dyspnea and to raise awareness among the critical care community about such a crucial patient reported outcome is welcome and essential.”
IV Calcium Before Diltiazem to Manage Rapid AF/AFL
The trial’s findings support IV calcium pretreatment for diltiazem-related hypotension.
Administering intravenous (IV) calcium prior to diltiazem in adults with atrial fibrillation (AF) with rapid ventricular response (RVR) and atrial flutter (AFL) can prevent drug-induced hypotension while preserving heart rate (HR) control, supporting its use as a stabilizing pretreatment in emergency settings.
“Reducing Diltiazem-Related Hypotension in Atrial Fibrillation: Role of Pretreatment Intravenous Calcium,” in The American Journal of Emergency Medicine, demonstrates that compared with placebo, pretreatment with IV calcium — at both 90 mg and 180 mg doses — sustained higher systolic blood pressure over a 15-minute post-diltiazem window. In addition, calcium pretreatment did not significantly affect the need for additional diltiazem dosing or influence adverse event rates, indicating it is a safe intervention.
The randomized, double-blind clinical trial enrolled 217 adults with AF/AFL and ventricular rate >120 bpm. Patients received either placebo or IV calcium chloride (90 mg or 180 mg) before diltiazem and were monitored for blood pressure, HR and adverse events over 15 minutes.
Patients who received 180 mg had higher HR at 10 and 15 minutes compared with the 90 mg and placebo groups, the trial adds. Systolic blood pressure was consistently higher in both calcium groups than the placebo group across all time points, with the 180 mg dose producing the most pronounced effect.
“In conclusion, calcium pretreatment mitigated the hypotensive effects of diltiazem by likely preserving vascular tone and myocardial contractility, ensuring stable blood pressure while maintaining effective HR control in patients with AF/AFL with RVR,” the trial notes.
The trial lists several limitations, including its single-center design, small sample size, brief follow-up period and lack of evaluation of HR control timing and underlying mechanisms. “Despite these limitations, our findings offer important evidence supporting IV calcium pretreatment for diltiazem-related hypotension.”
New Anti-Obesity Medications for Certain Patients With Heart Failure
Research may determine whether these anti-obesity drugs directly reduce the risks of cardiovascular events.
A scientific statement indicates two medications for obesity management show improvement in labs and imaging parameters for patients with certain types of heart failure (HF), even though the benefits have not yet been studied in focused trials.
“2025 ACC Scientific Statement on the Management of Obesity in Adults With Heart Failure: A Report of the American College of Cardiology,” in Journal of the American College of Cardiology (ACC), notes that the weight-loss benefits from semaglutide and tirzepatide in patients with HF with preserved ejection fraction (HFpEF) may reduce further cardiovascular events. “Given emerging evidence of the benefits … in concert with healthy behavioral interventions, clinicians should be aware of optimal diagnosis, risk assessment and management of obesity in individuals with HF,” the statement notes.
The wide-ranging statement explores several aspects of obesity and its relationship to HF, including the accuracy of defining and diagnosing it and varying methods of measuring besides using BMI as a standard despite its limitations. “Anthropometric measures — such as waist circumference, waist-to-hip ratio, waist-to-height ratio, or body roundness index — may better represent visceral adiposity and the potential to derive clinical benefit from obesity treatment.”
In addition to reviewing lifestyle interventions and bariatric surgery options, the statement examines evidence supporting the new medications. “Insufficient evidence [exists] to date to confidently conclude that semaglutide and tirzepatide reduce HF events in individuals with HFpEF and obesity (with stronger evidence for tirzepatide), although exploratory analysis indicates favorable changes in biomarkers and imaging parameters suggesting potential distinct mechanistic advantages outside of weight loss.”
The statement suggests research to determine if these medications directly reduce the risk of cardiovascular events. “It remains unclear at present whether more potent weight loss effects would be expected to exert even more HF benefit and what degree weight loss will confer the greatest benefit.”
President’s Column: Be On Purpose With Each Other
Purpose and joy are intertwined, but as nurses, we may be dedicating ourselves to purpose with less regard for our own comfort and joy. In her column, AACN President Rebekah Marsh explores ways we can "be on purpose with each other," to build stronger relationships and help us find joy in our purpose.
AI: Friend or Foe?
As artificial intelligence (AI) becomes increasingly prevalent in our daily lives, our views on it are split, especially in nursing: Is AI a friend or a foe? Kenrick Cato, a nurse scientist and professor of informatics at Penn Nursing, helps debunk the concern that AI is impersonal or job-threatening. And there’s evidence to support his view.