/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/,

/clinical/cckm-tools/content/order-sets/inpatient/bmtoncologyhematology/name-97828-en.cckm

201705146

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,BMT/Oncology/Hematology

IP - BMT - Blood Transfusion Delegation Protocol - Supplemental [4179]

IP - BMT - Blood Transfusion Delegation Protocol - Supplemental [4179] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, BMT/Oncology/Hematology


IP - BMT - Blood Transfusion Delegation Protocol - Supplemental [4179]
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
Blood and Bone Marrow Transplant (BMT)
Service Transfusion Protocol
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/inpatient-delegation-protocols/name-
97281-en.cckm
Medications - Pre-medications
Analgesics (Single Response) [113151]
acetaMINOPHEN (TYLENOL) tab [34149] 325 mg, Oral, ONCE PRN For 1 Doses, pain,
premedication for blood products
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE For 1 Doses
Premedication for blood products
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
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) [800005]
15 mg/kg, Oral, ONCE For 1 Doses
Premedication for blood products
NOTE: Suggested dose 15 mg/kg (Maximum 650
mg/dose)
Antihistamines (H1) (Single Response) [112527]
diphenhydramine (BENADRYL) cap [36791] 25 mg, Oral, ONCE For 1 Doses
Premedication for blood products
diphenhydramine (BENADRYL) cap [36791] 50 mg, Oral, ONCE For 1 Doses
Premedication for blood products
diphenhydramine (BENADRYL) injection 25 mg
[800106]
25 mg, Intravenous, ONCE For 1 Doses
Premedication for blood products
diphenhydramine (BENADRYL) injection 50 mg
[800106]
50 mg, Intravenous, ONCE For 1 Doses
Premedication for blood products
diphenhydramine (BENADRYL) injection 1 mg/kg
[800106]
1 mg/kg, Intravenous, ONCE For 1 Doses
Premedication for blood products
H2 Blockers (Single Response) [112526]
ranitidine (ZANTAC) tab [52786] 150 mg, Oral, ONCE For 1 Doses
Premedication for blood products
ranitidine (ZANTAC) injection [800075] 50 mg, Intravenous, ONCE For 1 Doses
Premedication for blood products
Steroids (Single Response) [113152]
dexamethasone (DECADRON) intraVENOUS
[800037]
Intravenous, ONCE For 1 Doses
Premedication for blood products
hydrocortisone sod suc in sodium chloride 0.9%
injection [800189]
1 mg/kg, Intravenous, ONCE For 1 Doses
Premedication for blood products
Laboratory (Post Infusion)
Laboratory [113153]
Page 1 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2017CCKM@uwhealth.org

HEMOGLOBIN [HGB] CONDITIONAL - RN COLLECT, Starting today 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 [PLT] 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
Red Blood Cells - Adult (Single Response) [223088]
Select indication below.
R1-Life-threatening hemorrhage or
anticipated/ongoing surgical blood loss [207820]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R1 Life-threatening hemorrhage
or anticipated/ongoing surgical blood loss
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed: 5/25/2017
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):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT 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:
R2-Suspected bleeding, symptomatic or drop in
Hemoglobin >= 3 g/dL or Hematocrit drop >= 10
[207821]
Page 2 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R2 Suspected bleeding,
symptomatic or drop in Hemoglobin >= 3 g/dL or
Hematocrit drop >= 10
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed: 5/25/2017
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):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT 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:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [214777]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R3 Target Hemoglobin >= 7
g/dL or Hematocrit >= 21% in acute upper GI
bleeds
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: 5/25/2017
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):
Consent Status:
Indication for Irradiated Blood:
Page 3 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT 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:
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients [214778]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R4 Target Hemoglobin >= 7 g/dL
or Hematocrit >= 21% in stable, nonbleeding
patients
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: 5/25/2017
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):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT 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:
R5-Target Hemoglobin >= 8 g/dL or Hematocrit
>= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases signif [214779]
Page 4 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R5 Target Hemoglobin >= 8 g/dL
or Hematocrit >= 24% in patients who are
myelosuppressed/bone marrow transplant or
symptomatic and with diseases significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
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: 5/25/2017
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):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT 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:
R6 High risk patients (e.g., ECMO, TAAA,
stroke/cerebral vasospasm, Sickle Cell Disease)
[207849]
Page 5 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R6 High risk patients (e.g.,
ECMO, TAAA, stroke/cerebral vasospasm, Sickle
Cell Disease)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed: 5/25/2017
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):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT 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:
R7-Massive Transfusion Procedure [207850]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R7 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed: 5/25/2017
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):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Indication for Irradiated Blood:
Page 6 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT 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:
R8-Other [207851]
Red Blood Cells (Adult) [BLB0006] 1 UNIT For 1 Occurrences, Routine
Reason for Order: R8 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed: 5/25/2017
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):
Consent Status:
Washed Product (Requires pathology review, call
263-8367):
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT 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:
Red Blood Cells - Pediatric (Single Response) [223098]
indication below.Select
PR1-(Patient younger than 4 months) Acute
blood loss or anticipated surgical blood loss
[214359]
Page 7 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR1 (Patient younger than 4
months) Acute blood loss or anticipated surgical
blood loss
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR2-(Patient younger than 4 months) Target
Hemoglobin > 7 g/dL or Hematocrit > 21% in
stable patient with signs of anemia (RA or nasal
cannula with Fi [214360]
Page 8 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR2 (Patient younger than 4
months) Target Hemoglobin > 7 g/dL or Hematocrit
> 21% in stable patient with signs of anemia (RA or
nasal cannula with FiO2 < 25%, and reticulocyte
count < 4%)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR3-(Patient younger than 4 months) Target
Hemoglobin > 8 g/dL or Hematocrit > 24% with
mild lung disease, NC/CPAP/NIPPV with FiO2 <
40%, and signs of [214361]
Page 9 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR3 (Patient younger than 4
months) Target Hemoglobin > 8 g/dL or Hematocrit
> 24% with mild lung disease, NC/CPAP/NIPPV
with FiO2 < 40%, and signs of poor oxygenation
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR4-(Patient younger than 4 months) Target
Hemoglobin > 10 g/dL or Hematocrit > 30% with
severe lung disease, intubated or on
nasopharyngeal synchroni [214362]
Page 10 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR4 (Patient younger than 4
months) Target Hemoglobin > 10 g/dL or
Hematocrit > 30% with severe lung disease,
intubated or on nasopharyngeal synchronized
intermittent mandatory ventilation with FiO2 > 40%,
congenital heart disease, and/or prematurity
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR5-Acute blood loss or anticipated surgical
blood loss [214364]
Page 11 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR5 Acute blood loss or
anticipated surgical blood loss
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR6-Target Hemoglobin > 7 g/dL or Hematocrit >
21% [214365]
Page 12 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR6 Target Hemoglobin > 7
g/dL or Hematocrit > 21%
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR7-Signs of poor oxygen delivery or target
Hemoglobin > 10 g/dL or Hematocrit > 30% in
patients with severe pulmonary disease requiring
assisted vent [214363]
Page 13 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR7 Signs of poor oxygen
delivery or target Hemoglobin > 10 g/dL or
Hematocrit > 30% in patients with severe
pulmonary disease requiring assisted ventilation or
congenital heart disease
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR8-Chronic transfusions in selected patients
with Sickle Cell or thalassemia syndromes OR
partial exchange or exchange transfusion
[214366]
Page 14 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR8 Chronic transfusions in
selected patients with Sickle Cell or thalassemia
syndromes OR partial exchange or exchange
transfusion
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR9-Massive Transfusion Procedure [214367]
Page 15 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR9 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PR10-Other [214368]
Page 16 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PR10 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT 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. Suggested dose:
10 mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Platelets - Adult (Single Response) [223109]
indication below.Select
P1-Target Platelets > 10 K/µL [214329]
Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P1 Target Platelets > 10 K/µL
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Page 17 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P2-Target Platelets >= 20 K/µL and central
venous catheter placement within 6 hours or
minor bleeding in BMT/leukemia-induction
patients [214341]
Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P2 Target Platelets >= 20 K/µL
and central venous catheter placement within 6
hours or minor bleeding in BMT/leukemia-induction
patients
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P3-Target Platelets > 50 K/µL and significant
bleeding or invasive procedure/surgery planned
within six hours (e.g., lumbar puncture,
nonneuraxial sur [214342]
Page 18 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P3 Target Platelets > 50 K/µL
and significant bleeding or invasive
procedure/surgery planned within six hours (e.g.,
lumbar puncture, nonneuraxial surgery)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P4-Target Platelets > 100 K/µL with major
CNS/eye surgery, for up to 48 hrs. post op,
epidural catheters and lumbar drains [214345]
Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P4 Target Platelets > 100 K/µL
with major CNS/eye surgery, for up to 48 hrs. post
op, epidural catheters and lumbar drains
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Page 19 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P5-Platelet dysfunction and ongoing bleeding
[214346]
Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P5 Platelet dysfunction and
ongoing bleeding
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P6-Massive Transfusion Procedure [214347]
Page 20 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P6 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
P7-Other [214348]
Platelets (Adult) [BLB0004] 1 SINGLE For 1 Occurrences, Routine
Reason for Order: P7 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE For 1 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Each Unit Over:
Page 21 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Platelets - Pediatric (Single Response) [223117]
indication below.Select
PP1-Target Platelets > 20 K/µL in a stable
premature infant (GA < 37 weeks) [214378]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP1 Target Platelets > 20 K/µL
in a stable premature infant (GA < 37 weeks)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP2-Target Platelets > 30 K/µL in a sick
premature infant (GA < 37 weeks) or minor signs
of bleeding [214379]
Page 22 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP2 Target Platelets > 30 K/µL
in a sick premature infant (GA < 37 weeks) or minor
signs of bleeding
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP3-Target Platelets > 50 K/µL and extreme
prematurity (GA < 37 weeks) at high risk for IVH
or neonatal encephalopathy [214380]
Page 23 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP3 Target Platelets > 50 K/µL
and extreme prematurity (GA < 37 weeks) at high
risk for IVH or neonatal encephalopathy
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP4-Target Platelets > 10 K/µL in a non-bleeding
patient with failure of platelet production [214381]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP4 Target Platelets > 10 K/µL
in a non-bleeding patient with failure of platelet
production
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Page 24 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP5-Target Platelets > 20 K/µL in a non-bleeding
patient with failure of platelet production and risk
factors (sepsis, fever, coagulopathy, etc.)
[214382]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP5 Target Platelets > 20 K/µL
in a non-bleeding patient with failure of platelet
production and risk factors (sepsis, fever,
coagulopathy, etc.)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP6-Target Platelets > 50 K/µL with failure of
platelet production AND active bleeding OR need
for an invasive procedure [214386]
Page 25 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP6 Target Platelets > 50 K/µL
with failure of platelet production AND active
bleeding OR need for an invasive procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP7-Significant bleeding in a patient with a
qualitative platelet defect, regardless of platelet
count [214389]
Page 26 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP7 Significant bleeding in a
patient with a qualitative platelet defect, regardless
of platelet count
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP8-Target Platelets > 75 K/µL in a non-bleeding
patient on ECMO [214390]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP8 Target Platelets > 75 K/µL
in a non-bleeding patient on ECMO
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Page 27 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP9-Target Platelets > 100 K/µL with major
CNS/eye/cardiac surgery (for up to 48 hrs. post-
operatively) [214391]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP9 Target Platelets > 100 K/µL
with major CNS/eye/cardiac surgery (for up to 48
hrs. post-operatively)
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP10-Massive Transfusion Procedure [214398]
Page 28 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP10 Massive Transfusion
Procedure
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PP11-Other [214399]
Platelets (Pediatric) [BLB0011] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PP11 Other
Specify Other Reason:
Blood Product Need (It will take approximately 30
to 60 minutes from the time nursing notifies the
Blood Bank to prepare the products):
Date Product Needed:
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):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Indication for Irradiated Blood:
Page 29 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org

Transfuse Platelets (Pediatric) [NURTRT0036] 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: Complete request to
dispense 30-60 minutes before transfusion to
prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Page 30 of 30
Printed by STRAKA, KEVIN F [KFS1] at 5/25/2017 4:54:53 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
05/2017CCKM@uwhealth.org