Search

Blood Request Private

Uploaded by Gecai Osial

 0 ratings · 76 views · 2 pages

Document Information 
For OMMC

Download
Copyright 
© © All Rights Reserved

Available Formats
DOCX, PDF, TXT or read online from Scribd
PHILIPPINE NATIONAL BLOOD SERVICES PROGRAM
OSPITAL NG MAYNILA MEDICAL CENTER
Share this document
BLOOD REQUEST FORM

DATE: HOSPITAL NUMBER:_________________

PATIENT:
Facebook Twitter AGE: SEX:_______
(SURNAME) (FIRST NAME) (MIDDLE NAME)
________________________________________________________________________________________


PHYSICIAN: ______________________________________DEPT/WARD/ER: ________________________
COMPLETE CLINICAL DIAGNOSIS: __________________________________________________________

Email
PATIENT’S BLOOD TYPE: __________ Rh: _________

HISTORY OF PREVIOUS TRANSFUSION: WHEN: __________________

WHERE: _________________
Did you find this document useful?
CHECK THE COMPONENT NEEDED AND INDICATION FOR TRANSFUSION:

( ) WHOLE BLOOD (APPROXIMATE VOLUME 500 ml):

( ) WB 1. Active bleeding with at least one of the following:
a. Loss of over 15% of blood volume
b. HB less than 9 g/dL
c. Blood pressure decrease over 20 % or less than 90 mmHg systolic
( ) WB 2. Others. Please specify (This code will automatically trigger a review of your indication)

Is( )this content

PACKED inappropriate?
RBC (APPROXIMATE Report this Document
VOLUME 250 ML)
( ) R – 1: Hb less than 8 g/dL or Hct less than 24% (if not due to treatable cause)
( ) R – 2: Patients receiving general anesthetic if:
a. Pre-operative Hb less than 8 g/dL or Hct less than 24 %
b. Major blood letting operation and HB less than 10 g/dL or Hct less than 30%
c. Signs of hemodynamic instability or inadequate oxygen carrying capacity (symptomatic anemia)
( ) R – 3: Symptomatic anemia regardless of Hb level (dyspnea, syncope, postural hypotension, tachycardia, chest pains, TIA)
( ) R – 4: Hb less than 8 g/dL or Hct less than 24 % with concomitant hemorrhage, COPD, CAD, hemoglobinopathy, sepsis
( ) R – 5: Others: Please specify (This code will automatically trigger a review of your indication)

( ) WASHED PRBC (APPROXIMATE VOLUME 180 ML)

( ) WP – 1: History of previous severe allergic transfusion reactions or anaphylactoid reactions in immunocompromised
patients
( ) WP – 2: Transfusion of group “O blood during emergencies when the specific blood is not immediately available.
( ) WP – 3: Paroxysmal Nocturnal Hemoglobinuria
( ) WP – 4: Others. Please specify (This code will automatically trigger a review of your indication)
Note: Comments on RBC products
1. Document pre- and post-transfusion Hb and Hct within 24 hours.
2. Dose: Adults – give on a unit-to-unit basis
Remember, 1 unit may suffice to alleviate symptoms of anemia
Infants: 10 mL/kg BW

ADVERTISING

( ) PLATELETS (APPROXIMATE VOLUME 50 ML)

( ) P – 1: Prophylactic administration with count <20, 000 and not due to TIP, ITP, HUS
( ) P – 2: Active bleeding with count < 50, 000
( ) P – 3: Platelet count <50, 000 and patient to undergo invasive procedure within 6 hours
( ) P – 4: Platelet count less than 100, 000 if surgery is on critical area (e.g., Eye, brain, etc.)
( ) P – 5: Massive transfusion with diffuse microvascular bleeding and no time to obtain platelet ct.
( ) P – 6: Others. Please specify (This code will automatically trigger a review of your indication)
Note: Document platelet count before (within 8 hrs and after (within 1 hr) transfusion.
Dose: 1 unit/10 kg BW with maximum of 8 units

( ) CRYOPRECIPITATE (APPROXIMATE VOLUME 20 ML)

( ) C – 1: Significant hypofibrogenemia (<100 mg/dL)
( ) C – 2: Hemophilia A
( ) C – 3: Von WIllebrand’s disease or uremic bleeding with prolonged bleeding time
( ) C – 4: Others. Please specify (This code will automatically trigger a review of your indication)

( ) FRESH FROZE PLASMA (APPROXIMATE VOLUME 200- 250 ml)

( ) F – 1: PT or PTT > 1.5 times mid-normal range within 8 hrs of transfusion (PT >17 s, PTT > 47 s)
( ) F – 2: Specific Factor deficiencies not treatable with cryoprecipitate
( ) F – 3: Reversal of coumadin anticoagulation in bleeding patient s and not treatable with Vit. K
( ) F – 4: Treatment of TTP
( ) F – 5: Clinical coagulopathy associated with:
a. Massive transfusion (>20 units of blood in 24 hrs)
b. Late pregnancy termination or abruption placentae
( ) F – 6: Others. Please specify (This code will automatically trigger a review of your indication)
Note: 1. Document PT/PTT pre- and post-transfusion within 4 hrs.
2. Dose: 10 ml/kg/BW or initial loading doe of 15 ml/kg/BW
Correction of significant coagulopathy requires >2 units FFP

NO. OF UNITS NEEDED: ________________________________________

OTHERS/REMARKS:

_____________________________________________
REQUESTING PHYSICIAN
SIGNATURE OVER PRINTED NAME

Share this document

    

You might also like

Document 2 pages

BLOOD REQUEST FORM (ADULT)

peanutbutter oh
50% (2)

Document 17 pages

Massive blood transfusion

evan
No ratings yet

Document 29 pages

Massive Transfusion and

Coagulopathy
Mahavir Gemavat
No ratings yet

Magazines Podcasts

Sheet music

Document 38 pages

Sepsis 31st Jan

prashsubbu
100% (1)

Document 38 pages

Sepsis 31st Jan Modified

prashsubbu
No ratings yet

Document 6 pages

Soapie Sheet ‫حامد‬

Hamed althoweni
No ratings yet

Document 33 pages

Blood Component
matrixtrinity
No ratings yet

Document 32 pages

EGDT
dr.mahens
No ratings yet

Document 28 pages

Blood Transfusion
hanibalbal
No ratings yet

Document 5 pages

Blood Transfusion
Rosalinda Aquino Cruz
No ratings yet

Document 12 pages

Massive Transfusion Protocols

Ehrli Cuaresma
No ratings yet

Document 4 pages

Blood transfusion
SherineBelza
No ratings yet

Show more

About Support

About Scribd Help / FAQ

Press Accessibility

Our blog Purchase help

Join our team! AdChoices

Contact us Publishers

Invite friends
Social
Gi!s

Scribd for enterprise Instagram

Twitter
Legal Facebook

Terms Pinterest

Privacy

Copyright

Cookie Preferences

Do not sell or share my

personal information

Get our free apps

Audiobooks • Books • Documents • Magazines •

Podcasts • Sheet music

Language: English

Copyright © 2023 Scribd Inc.

Download