Standing Orders Exchange Transfusion

Affix Patient Identification Sticker in this Area.

Allergies: Date & Time

Exchange Transfusion Protocol:
Take a base line set of vital signs Take vital signs every 5 minutes during phlebotomy then as per blood transfusion policy. ____Type and cross for ________units of blood. ____Blood consent if not already obtained. Labs before exchange: ___HGB ___HCT ____Hemoglobin Electrophoresis

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Labs after exchange: ___HGB ____HCT ____Hemoglobin Electrophoresis

5. Amount of blood phlebotomized from patient each day: _________Day one _________Day two _________Day three _________Day four Note: • The maximum amount of blood that can be withdrawn in a 24-hour period is 500cc. • Stop removal of blood if patients systolic B/P is <90. Continue monitoring B/P until B/P returns to baseline then proceed with phlebotomy. 6. Number of PRBC units transfused per day: _________Day one _________Day two _________Day three _________Day four 7. Replacement fluid ___________cc/hour _____ Normal Saline _____Normal Saline with 20 mEq/L Potassium Chloride 8. Fluid Bolus before phlebotomy ____________cc/hour _____Normal Saline _____Normal saline with 20 mEq/L Potassium Chloride

MD Signature ________________________________Date:__________ Time:________ Effective: Reviewed/Revised:

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