Date tiMe oncology transfusion orDers Diagnosis: : consent for ProceDure to be PerforMeD: consent for transfusion of blood or blood Products (fM# 5766) lab results: Hgb______Hct______Platelets______general 1. notify MD Stop transfusion and notify physician for: Fever with or without chills (increase of more than 2˚ F), shaking chills with or without fever Respiratory distress, including dyspnea, tachypnea, wheezing, or hypoxemia Chest pain, back pain, infusion site pain Nausea with or without vomiting Urticaria including hives, rash, and itching Hematuria labs 1. general labs Daily CBC Type and Screen if not done in last 72 hours 2. nursing inDications for For less than or equal to 7 g/dl - Transfuse 1 unit (PRBC) For less than or equal to 10 x 103/uL - Transfuse 1 unit Platelets If bleeding and level less than 50 x 103/uL - Transfuse 1 unit Apheresis Platelets and notify MD use only leukoreduced blood products. use only irradiated blood products for patients with leukemia or for patients with anc less than or equal to 1000/ul.

2. q PackeD reD blooD cells (Prbc) lab to prepare Prbc transfusion Number of units: 1 Intended transfusion date ______Special Requirements: q Irradiated q CMV Negative q Leukoreduced q Sickle Cell Negative q Other:

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oncology blooD transfusion orDers fM# 3043 Pub. 10/19 Page 1 of 3 UCO TAB – PHYSICIAN ORDERS Date tiMe oncology blooD transfusion orDers PackeD reD blooD cells (Prbc) - continued nursing to transfuse/hold Prbc’s Units to transfuse now: ______Units to hold: ______Transfusion Indications: q Hematocrit 21% or less OR hemoglobin 7 g/dL or less for q Hematocrit 24% or less OR Hemoglobin 8 g/dL or less in a patient with coronary artery disease and unstable angina / / cardiogenic for anemia q Blood loss associated with HYPOtension and/or HYPOvolemia for anemia q Other: ______q Hold unit(s) for Surgery Date ______

q Platelets aPHeresis A single dose of platelets (Adult: one pheresis unit; Pediatric: 5-10 ml/kg) will usually increase the platelet count by 25k- 35k/ul 1 Unit of Apheresis Platelets = 6 Units of pooled Platelets. Blood Bank will provide 1 unit for infusion. lab to prepare Platelet apheresis Number of units ______Intended transfusion date ______Special Requirements: q Irradiated q CMV Negative q Leukoreduced q Other ______nursing to transfuse/hold Platelet apheresis Units to transfuse now: ______Units to hold: ______Transfusion Indications: q Platelet count <10k/uL prophylactically for failure of platelet production q Platelet count <20k/uL prophylactically prior to central venous catheter placement q Platelet count <50k/uL prophylactically prior to lumbar puncture q Platelet count <50k/uL prophylactically for major elective non-neuraxial surgery q Platelet count <50k/uL prophylactically for cardiac surgery w/cardiopulmonary bypass for peri-op bleeding w/thrombocytopenia and/or evidence of platelet dysfunction q Special circumstances (specify): ______q Hold unit(s) for Surgery Date ______

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lee HealtH lee county, florida

oncology blooD transfusion orDers fM# 3043 Pub. 10/19 Page 2 of 3 UCO TAB – PHYSICIAN ORDERS Date tiMe oncology blooD transfusion orDers q (ffP) lab to prepare ffP Number of Units ______Intended transfusion date ______nursing to transfuse/hold ffP’s Units to transfuse now: ______Units to hold: ______Transfusion Indications: q INR 2.0 or greater and invasive procedure (recent, in-progress, planned) q Other: ______Transfusion Duration per Unit: ______hours q Hold unit(s) for Surgery Date ______

MeDications 1. PriMer for blooD Saline primer for blood - 0.9% sodium chloride IV at 25 mL/hr 2. iv fluiDs Maintain saline lock/saline flush panel: a. Maintain IV access b. 0.9% Sodium Chloride 3-10 mL flush every 12 hours c. 0.9% Sodium Chloride 3-10 mL flush before and after IV medication administration and PRN 3. Pre-MeDications Current evidence does not support routine use of pre-medication for blood transfusions. Clinical judgment should be used in determining need on a case-by-case basis. q Diphenhydramine (Benadryl) 25 mg PO x 1 dose prior to transfusion q Acetaminophen (Tylenol) 650 mg PO within 30 minutes (1/2) prior to transfusion 3. otHer MeDications q Furosemide (Lasix) q 10 mg q 20 mg q 40 mg IV between units of transfusion PRN dyspnea Diphenhydramine (Benadryl) 25 mg IV PRN itching/hives. May repeat x 1.

Physician signature: ______Date:______time:______Physician Printed name: ______Physician number: ______rooM #: PHYSICIANS ORDERS

lee HealtH lee county, florida

oncology blooD transfusion orDers fM# 3043 Pub. 10/19 Page 3 of 3 UCO TAB – PHYSICIAN ORDERS