Date tiMe oncology blooD transfusion orDers Diagnosis: allergies: 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 blooD transfusion For Hemoglobin less than or equal to 7 g/dl - Transfuse 1 unit Packed Red Blood Cells (PRBC) For Platelets less than or equal to 10 x 103/uL - Transfuse 1 unit Apheresis Platelets If bleeding and Platelet 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. blooD bank 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: continued on page 2 rooM #: PHYSICIANS ORDERS lee HealtH lee county, florida 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 anemia q Hematocrit 24% or less OR Hemoglobin 8 g/dL or less in a patient with coronary artery disease and unstable angina / myocardial infarction / cardiogenic shock 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 ____________________ continued on page 3 rooM #: PHYSICIANS ORDERS 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 fresH frozen PlasMa (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. saline 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.