Health A.P.A Melbourne Health Shared Transfusion Lab: ph: 9342 7275 The Royal Melbourne Fax: 9342 7177 300 - 336 Grattan Street, Parkville VIC 3050 Transfusion Medicine Service NATA / RCPA Accredited

Doctor: Surname Initials UNIT: UR No. Address: Surname Given Name(s) Provider No. WARD: Address: Copy to 1. Date of Birth: 2. Sex: M o F o <50yrs o >50yrs o Unknown Age o

Red Cells: Valid X-Match required Hb: g/L Test(s) Requested:

Number Units

Special Requirements: Indication: Refer to NH & MRC guidelines - See Reverse Transfusion Test / Product Request Diagnosis/Reason: Code:

Platelets: Number of Bags: URGENT: (Phone Lab) #27275 Non Urgent o Date: Time:

Plt Count: x109/L Bleeding: Yes o No o Transfusion History & Pt Information: YES NO UNK 1. Transfusion in past 3 Months o o o FFP: Volume / Number of Bags: 2. Pregnancy / Miscarriage in past 3 months o o o 3. Current Pregnancy (gestation): wks INR patient Wt kg 4. Known Red Cell Antibodies: Cryoprecipitate: Number of Bags: Requesting Clinician to Complete:

Valid Blood Group Required Valid Fibrinogen: glL Name: (print if not as above)......

Medical Officer MUST Complete this area Please Signed ...... Date: ...... Other Products: (specify) Pager No Mobile No

Complete for all patients Patient Status at the time of specimen collection Y N MEDICARE ASSIGNMENT (Section 20A of the health Insurance Act 1973) a) Private patient in a private hospital, or approved day hospital facility? o o I assign my right to the approved pathology practitioner who will order the requested pathology b) Private patient in a recognised hospital? o o services. c) Public patient in a recognised hospital? o o Medicare ...... d) Outpatient of a recognised hospital? A/C CLASS o o Patient Signature:……………………………………… Date:………...... Hos o BB o Pte In / Out o Practitioner use only: reason patient cannot sign. W / C o TAC o Veterans o Overseas o

Person Drawing Blood (7.5 mL blood in a purple topped tube) to Complete: I confirm that I collected the blood samples accompanying this request from the patient named above, and that I confirmed the identity of this patient by direct inquiry and / or inspection of wristband; and immediately following collection, I labelled the specimen(s) with their Given name, Surname, UR number, date, time and verified this with my signature.

Signed:...... Surname: (print)...... Designation: Dr  RN  Phlebotomist  Collector Date Collected Time Collected Ward / Location:

Patient’s Blood Group Anti - A Anti - B Anti - A / B Anti - D Con A 1 B O Group Cells Cells Cells Sign

ABO Rh(D) B1 B2 Checked.. Loaded.. Group Special Conditions Plasma Saved Anti D BioVue 37oC RAM Valid TMS Lab Use Only NEW PATIENT’S CHECK NEW PATIENT’S

Anti B Antibodies I confirm that the blood group and antibody screen of the blood SC I specimen supplied to me and labelled with the identity of the SC II

Anti A patient whose name heads this form is as recorded on this form. SC III

Signed...... Date...... Antibody Screen: Detected Not Detected 681621_07/12 Code Based on the NH&MRC Clinical Practice Guidelines on the Use Of Blood Components. SEE GUIDELINES CENTRAL ON INTRANET FOR MORE DETAIL.

RED CELLS Volume: Red Cells LD: >200mL, LPF: >200mL, Paediatric LD: 25-100mL Recommended Administration Rate: completed within 4 hours commencement

Indication Considerations R1 Hb<70  Lower thresholds may be acceptable in patients without symptoms and/or where specific therapy is available. R2 Hb 70 - 100 Likely to be appropriate during surgery associated with major blood loss or if there are signs or symptoms of impaired oxygen transport. R3 Hb > 80 May be appropriate to control anaemia-related symptoms in a patient on a chronic transfusion regimen or during marrow suppressive therapy R4 Hb > 100 Not likely to be appropriate unless specific indications • Hb should not be the sole deciding factor. Consider also patient factors, signs and symptoms of hypoxia, ongoing blood loss and the risk to the patient of anaemia and the risk of the transfusion. FFP Volume: Std bag: 300mL, Paeds: 74mL, Cryo depleted > 165mL, Apheresis >500mL Recommended Administration Rate: Transfused as fast as tolerated and completed within 4 hours from commencement Dose:10-20 mL/Kg. Indication Considerations F1 Warfarin Effect In presence of life-threatening bleeding. Use in addition to Vitamin K dependent concentrates F2 Acute DIC In presence of bleeding and abnormal coagulation. NOT for chronic DIC F3 Liver disease In the presence of bleeding and abnormal coagulation. F4 Coagulation USE SPECIFIC FACTOR WHERE AVAILABLE Inhibitor Deficiencies PLATELETS Volume: Pooled >160mL, Apheresis: 100 – 400mL, Apheresis Paeds: 40-60mL Recommended Administration Rate: 1 bag transfused as fast as tolerated and completed within 4 hours from commencement

Indication Considerations P1a Bone Marrow No risk factors - administer at 10x109/L or less. P1b Failure With risk factors (fever, antibiotics etc.) administer at 20x109/L or less P2a Surgery Maintain Platelet count at > 50x 109/L P2 Surgery with high risk of bleeding (neuro/ocular) maintain > 100x 109/L Maybe appropriate in any patient in whom thrombocytopenia is considered a P2c major contributory factor. Platelet Function Administer platelets based on clinical features, not platelet count. Platelet count unreliable. P3 Disorders P4a Massive Use should be confined to patients with thrombocytopenia/ P4b Haemorrhage/ functional abnormalities that have significant bleeding from this cause Transfusion May be appropriate when the platelet count is < 50 x 109/L (<100 x 109/L in the presence of diffuse micro vascular bleeding.) CRYOPRECIPITATE Volume: Std bag: 10-40mL, Apheresis: 60ml Indication Considerations C1 Fibrinogen May be appropriate where there is clinical bleeding and invasive Deficiency procedure, trauma or DIC. TESTS AVAILABLE G&S (Group & Antibody Screen); XMatch (G&S and crossmatch units); G&S –JIC (just in case). DAT (Direct Antiglobulin Test); EGS (Extended G&S – for elective surgery only)

Your doctor has recommended that you use Melbourne Health Shared Pathology Service. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on the grounds, a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor. Patients Details Patients Details Patients Details

Surname:______Surname:______Surname:______

Given Name:______Given Name:______Given Name:______

UR: ______UR: ______UR: ______

DOB:______DOB:______DOB:______

Collector's Details_ Ward: ______Collector's Details_ Ward: ______Collector's Details_ Ward: ______

Name: ______Signature: ______Name: ______Signature: ______Name: ______Signature: ______

Date: ______Time: ______Date: ______Time: ______Date: ______Time: ______