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UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Inpatient Delegation Protocols,Related

BMT - Blood Transfusion - Supplemental

BMT - Blood Transfusion - Supplemental - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols, Related


SmartSet: IP - BMT - BLOOD TRANSFUSION - SUPPLEMENTAL (ID:4179)
General Information
Display name: IP - BMT - Blood Transfusion - Supplemental
Type: General
Merge priority: 0
Version comment:
Content source:
Synonyms:
SmartSet notes:
Description: 1) Choose premedications and post labs based on communication by provider in the "Initiate
BMT Service Transfusion Protocol" order
2) Sign orders with an order mode of "Cosign required Protocol/Policy"
3) To initiate the protocol:
· Hemoglobin needs to be less than or equal to 8 grams/deciliter
Platelet count needs to less than or equal to 10,000/microliter for adult patients;
20,000/microliter for pediatric patients or as ordered via the "Initiate BMT Service Transfusion
Protocol" order
Web information:
Title URL
1. Blood and Bone Marrow Transplant
(BMT) Service Transfusion Protocol
https://uconnect.wisc.edu/servlet/Satellite?
cid=1126670401328&pagename=B_EXTRANET_UWH_HOME%
2FFlexMemberFile%2FLoad_File&c=FlexMemberFile
Questionnaire:
Configuration
Medications - Pre-medications
Analgesics
acetaMINOPHEN (TYLENOL) tab 325 mg, Oral, ONCE PRN For 1 Doses, pain, premedication
for blood products
acetaMINOPHEN (TYLENOL) tab 650 mg, Oral, ONCE For 1 Doses
Premedication for blood products
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension
650 mg, Oral, ONCE For 1 Doses
Premedication for blood products
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose)
15 mg/kg, Oral, ONCE For 1 Doses
Premedication for blood products
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Antihistamines (H1)
diphenhydramine (BENADRYL) cap 25 mg, Oral, ONCE For 1 Doses
Premedication for blood products
diphenhydramine (BENADRYL) cap 50 mg, Oral, ONCE For 1 Doses
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Pr i nt ed by STRAKA, KEVIN F [KFS1] at 12/15/2014 4:27:49 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


Premedication for blood products
diphenhydramine (BENADRYL) injection 25 mg 25 mg, Intravenous, ONCE For 1 Doses
Premedication for blood products
diphenhydramine (BENADRYL) injection 50 mg 50 mg, Intravenous, ONCE For 1 Doses
Premedication for blood products
diphenhydramine (BENADRYL) injection 1 mg/kg 1 mg/kg, Intravenous, ONCE For 1 Doses
Premedication for blood products
H2 Blockers
ranitidine (ZANTAC) tab 150 mg, Oral, ONCE For 1 Doses
Premedication for blood products
ranitidine (ZANTAC) injection 50 mg, Intravenous, ONCE For 1 Doses
Premedication for blood products
Steroids
dexamethasone (DECADRON) intraVENOUS Intravenous, ONCE For 1 Doses
Premedication for blood products
hydrocortisone sod suc in sodium chloride 0.9%
injection
1 mg/kg, Intravenous, ONCE For 1 Doses
Premedication for blood products
Laboratory (Post Infusion)
Laboratory
HEMOGLOBIN CONDITIONAL - RN COLLECT, Starting S For 1 Days,
Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? release 1 hour post-infusion of
red blood cells
PLATELET COUNT CONDITIONAL - RN COLLECT For 1 Days, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Release 1 hour post-infusion
of platelets
Blood Products - BMT Protocol
Blood Products
Red Blood Cells (Pediatric) Routine
Reason for Order: PR13 Other (Specify in comments)
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): NON-SURGICAL USE
Date Product Needed: 12/15/2014
Has consent been obtained? Yes
Date Consent Obtained (Valid for 1 year):
Total Volume (mL):
Uncrossmatched **WARNING** Requesting MD verifies that
the clinical situation is sufficiently urgent to require release of
blood before completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history): Yes
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history):
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Pr i nt ed by STRAKA, KEVIN F [KFS1] at 12/15/2014 4:27:49 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


Volume-Reduced (May be pre-selected based on history):
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose: 10 mL/kg
body weight.
Platelets (Pediatric) Routine
Reason for Order: PP11 Other (Specify in comments)
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): NON-SURGICAL USE
Date Product Needed: 12/15/2014
Has consent been obtained? Yes
Date Consent Obtained (Valid for 1 year):
If ordering < 1 unit specify the Total Volume to be transfused
(mL):
Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history): Yes
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history):
Volume-Reduced (May be pre-selected based on history):
Patient Weight
No data found for Wt
For refractory patients, call Blood Bank at 263-8367.
Suggested dose = 10-20 mL/kg body weight for neonatal and
pediatric patients. For patients greater than 60 kg, suggested
dose is 1 Single Donor Unit. 1 Single Donor Unit = 200-250
mL. All platelet products are leukocyte-reduced (CMV safe).
NURSING REMINDER: Call the Blood Bank at 3-8367 30-60
minutes before transfusion to prepare products.
Blood Products
Red Blood Cells (Adult) 2 UNITS For 2 Occurrences, Routine
Reason for Order: R7 Other (Specify in comments)
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): NON-SURGICAL USE
Date Product Needed: 12/15/2014
Has consent been obtained? Yes
Date Consent Obtained (Valid for 1 year):
Uncrossmatched **WARNING** Requesting MD verifies that
the clinical situation is sufficiently urgent to require release of
blood before completion of compatibility testing and agrees to
hold UWHC harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history): Yes
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history):
Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV safe)
1 Red Blood Cell Unit ~ 350 mL.
Platelets (Adult) 4 RANDOM/1 SINGLE For 1 Occurrences, Routine
Reason for Order: P4 Other (Specify in comments)
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): NON-SURGICAL USE
Date Product Needed: 12/15/2014
Has consent been obtained? Yes
Page 3 of 5
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 12/15/2014 4:27:49 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


Date Consent Obtained (Valid for 1 year):
Irradiated (See Blood Product Guidelines) (May be pre-
selected based on history): Yes
CMV Negative (Heart/Lung Transplant and Neonates up to 4
Months Only) (May be pre-selected based on history):
Patient Weight
No data found for Wt
For refractory patients, call Blood Bank at 263-8367.
1 Single Donor Unit ~ 200-250 mL.
All platelet products are leukocyte-reduced (CMV safe).
NURSING REMINDER: Call Blood Bank at 3-8367 30-60
minutes before transfusion to prepare products.
Transfusion - BMT Protocol
Transfusion
Transfuse Red Blood Cells (Pediatric) Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose: 10 mL/kg
body weight.
Total Volume (mL):
Run Over: 2 Hours
Transfuse Platelets (Pediatric) Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose = 10-20
mL/kg body weight for neonatal and pediatric patients. For
patients greater than 60 kg, suggested dose is 1 Single Donor
Unit.
NURSING REMINDER: Call Blood Bank at 3-8367 30-60
minutes before transfusion to prepare products.
Type of platelets:
Run Over: 30 Minutes
Transfusion
Transfuse Red Blood Cells (Adult) TRANSFUSE 2 UNITS For 1 Occurrences, Routine, Patient
Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over: Other (Comments)
Transfuse Platelets (Adult) TRANSFUSE 4 UNITS For 1 Occurrences, Routine, Patient
Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Call Blood Bank at 3-8367 30-60
minutes before transfusion to prepare products.
Type of platelets: Random
Run Each Unit Over: 30 Minutes
Criteria
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Pr i nt ed by STRAKA, KEVIN F [KFS1] at 12/15/2014 4:27:49 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison


Suggestions: UWIP C LOGIN DEPT IP ONCOLOGY/HEMATOLOGY/BMT[3001756]
Filter: UWIP ORDERSET RESTRICTOR - RN AND PT ON PP41 OR B6/6 - NOT IP DC[3000475]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders display:
Release date: Use System Definitions Setting
Disallow user override:
Page 5 of 5
Pr i nt ed by STRAKA, KEVIN F [KFS1] at 12/15/2014 4:27:49 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison