PHILIPPINE NATIONAL BLOOD SERVICES PROGRAM

OSPITAL NG MAYNILA MEDICAL CENTER

BLOOD REQUEST FORM

DATE: HOSPITAL NUMBER:_________________
PATIENT: AGE: SEX:_______
(SURNAME) (FIRST NAME) (MIDDLE NAME)
________________________________________________________________________________________
PHYSICIAN: ______________________________________DEPT/WARD/ER: ________________________
COMPLETE CLINICAL DIAGNOSIS: __________________________________________________________

PATIENTS BLOOD TYPE: __________ Rh: _________

HISTORY OF PREVIOUS TRANSFUSION: WHEN: __________________
WHERE: _________________

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)

( ) PACKED RBC (APPROXIMATE 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



( ) 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 WIllebrands 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