EASTERN VISAYAS REGIONAL MEDICAL CENTER BLOOD REQUEST

Tacloban City, Philippines 6500 FORM (ADULT)

Date:
Date and Time received:______________________Date and Time Assigned:__________________________________

Name of Patient: Age: Sex:

Surname First Name Middle Name
Address: ____________________________________________________________ Birthday:______________________
Attending Physician: Ward: Room# Hosp.#

Patient's Blood Type: Rh

History of Previous Transfusion: When:
Where:
Clinical Diagnosis:
Type of Request: ( ) ROUTINE ( ) STAT
Check components Needed and Indication for Transfusion
( ) Whole Blood (Approximate volume 500 ml)
( ) WB-1: Active bleeding with at least one of the following
a. Loss over 15% blood volume
b. Hemoglobin less than 9 g/dl
c. Blood pressure decrease over 20* or less than 90 mm Hg systolic
( ) WB-2: Others please specify. (This code will automatically trigger a review of your indication)
( ) Packed Red Blood Cells (approximate volume 250 ml)
( ) RBC-1 Hemoglobin less than 8 gm/dl or Hct less than 42% (if not due to treatable cause.)
( ) RBC-2 Patients receiving general anesthesia if:
a. Preoperative Hgb is less than 8 gm/dl or Hct is less than 24%
b. Major blood letting operation and Hgb is less than 30%
c. Sign of Hemodynamic instability or inadequate oxygen carrying capacity
(symptomatic anemia)
( ) RBC-3 Symptomatic anemia regardless of Hgb level (dyspnea, syncope, postural
hypotension, tachycardia, chest pains)
( ) RBC-4 Hgb less than 8 gm/dl or Hct less than 24% with concomitant hemorrhage, COPD,
CAD, Hemoglobinopathy, sepsis.
( ) RBC-5 Others please specify (This code will automatically trigger a review of your indication)
( ) Washed RBC (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 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. Documents pre-and post-transfusion Hgb and Hct within 24 hours
2. Dose; adult-give on a unit-to-unit basis
Remember: 1 unit may suffice to alleviate symptoms of anemia
Infants: 10 ml/Kg. Body weight
( ) Platelet Concentrate (approximate volume 50 ml)
( ) P-1 Prophylactic administration with count ≤ 20,000 and not due to TTP, ITP, HUS
( ) P-2 Active bleeding with count ≤ 50,000.

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 ( ) P-3 Platelet count ≤ 50,000 and patient to undergo invasive procedure within 8 hours.
( ) P-4 Platelet count ≤ 100,000 if surgery in on critical area (e.g. eye, brain, etc.)
( ) P-5 Massive transfusion with diffuse microvascular bleeding and no time to obtain platelet
count.
( ) P-6 Others please specify (This code will automatically trigger a review of your indication)

( ) Fresh Frozen Plasma (approximate volume 200-250 ml)

( ) F-1 PT or PTT 1.5 times mid normal range within 8 hrs. of transfusion (PT17 secs, PTT 47 secs)
( ) F-2 Specific factor deficiencies not treatable with cryoprecipitate
( ) F-3 Reversal of Coumadin anticoagulation in patient who are bleeding and not treatable with
vitamik K.
( ) F-4 Treatment of TTP
( ) F-5 Clinical coagulopathy associated with:
a. Massive transfusion (≤ 20 units of blood in 24 hours)
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 hours.
2. Dose: 10 ml/Kg BW or initial loading dose of 15 ml/Kg BW
Correction of significant coagulopathy requires > 2 units of FFP

( ) Cryoprecipitate (approximate volume 20 ml)

( ) C-1 Significant hypofibrinogemia (< 100 mg/dl)
( ) C-2 Hemophilia A
( ) C-3 Von Willebrands disease or uremic bleeding with prolonged bleeding time.
( ) C-4 Others please specify (This code will automatically trigger a review of your indications)

No. of units needed: ________________________________________________________________________________

Type of Crossmatching

( ) Saline Phase only

( ) saline, Albumin Phase
( ) Saline, Albumin, Globulin Phase

Others: ____________________________________________________________________________________________
Remarks: __________________________________________________________________________________________

_____________________________________
REQUESTING PHYSICIAN

___________________________________________________________________________________________________

Received by: ______________________________________ Date/Time: _____________________________________

Extracted by: ______________________________________ Date/Time: _____________________________________

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