/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/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98180-en.cckm

201704115

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP - Blood Transfusion - Adult - Supplemental [996]

IP - Blood Transfusion - Adult - Supplemental [996] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Blood Transfusion - Adult - Supplemental [996]
for Adult Patients OnlyIntended
Tests
Tests [100542]
TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, As good clinical practice and
for patient safety, the Transfusion Service will
automatically crossmatch 2 packed RBCs on all
patients with antibodies to ensure blood would be
available in the event it is needed. If you would like to
opt out of this automatic order for this patient please
contact the UWHC Blood Bank at (608) 263-8367 or
The American Center Lab at (608) 234-6600 as
appropriate.
Tests [100543]
TYPE AND SCREEN, NEONATAL [HCNTS] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Blood Products
Red Blood Cells - Adult (Single Response) [206670]
Select indication below. When appropriate, the system will automatically suggest the appropriate number
@BUCWTMSG@of units for this patient based on the indication.
For more information about the Blood Utilization
Calculator (BUC) click here
URL: https://uconnect.wisc.edu/clinical/references/laboratory-
services/transfusion-services-uwhc/resources/name-
101746-en.file
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): NON-
SURGICAL USE
Date Product Needed: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 1 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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:
R2-Suspected bleeding, symptomatic or drop in
Hemoglobin >= 3 g/dL or Hematocrit drop >= 10
[207821]
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): NON-
SURGICAL USE
Date Product Needed: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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 [NO RECENT
HEMOGLOBIN/HEMATOCRIT, UNABLE TO
CALCULATE VOLUME] [207822]
Page 2 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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 [NO
HEMOGLOBIN/HEMATOCRIT RESULT SINCE
LAST BLOOD ORDER, UNABLE TO
CALCULATE VOLUME] [210389]
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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 3 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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:
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=0 UNITS]
[207823]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require blood at
this time because they are already above the
target hemoglobin/hematocrit level. Select a
different indication or exit the order set.
[NURCOM0022]
ONCE
R3-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in acute upper GI bleeds [CALCULATED
VOLUME FOR THIS PATIENT=1 UNIT] [207824]
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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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 [CALCULATED
VOLUME FOR THIS PATIENT=2 UNITS]
[207825]
Page 4 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 2 UNITS For 2 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 2 UNITS For 2 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 [CALCULATED
VOLUME FOR THIS PATIENT=3 UNITS]
[207826]
Red Blood Cells (Adult) [BLB0006] 3 UNITS For 3 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 5 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 3 UNITS For 3 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 [CALCULATED
VOLUME FOR THIS PATIENT=4 UNITS]
[207827]
Red Blood Cells (Adult) [BLB0006] 4 UNITS For 4 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 4 UNITS For 4 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 [CALCULATED
VOLUME FOR THIS PATIENT=5 UNITS]
[207828]
Page 6 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 5 UNITS For 5 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 5 UNITS For 5 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 [NO
RECENT HEMOGLOBIN/HEMATOCRIT,
UNABLE TO CALCULATE VOLUME] [207829]
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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 7 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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 [NO
HEMOGLOBIN/HEMATOCRIT RESULT SINCE
LAST BLOOD ORDER, UNABLE TO
CALCULATE VOLUME] [210435]
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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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
[CALCULATED VOLUME FOR THIS
PATIENT=0 UNITS] [207830]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require blood at
this time because they are already above the
target hemoglobin/hematocrit level. Select a
different indication or exit the order set.
[NURCOM0022]
ONCE
R4-Target Hemoglobin >= 7 g/dL or Hematocrit
>= 21% in stable, nonbleeding patients
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT] [207831]
Page 8 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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
[CALCULATED VOLUME FOR THIS
PATIENT=2 UNITS] [207832]
Red Blood Cells (Adult) [BLB0006] 2 UNITS For 2 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 9 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 2 UNITS For 2 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
[CALCULATED VOLUME FOR THIS
PATIENT=3 UNITS] [207833]
Red Blood Cells (Adult) [BLB0006] 3 UNITS For 3 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 3 UNITS For 3 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
[CALCULATED VOLUME FOR THIS
PATIENT=4 UNITS] [207834]
Page 10 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 4 UNITS For 4 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 4 UNITS For 4 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
[CALCULATED VOLUME FOR THIS
PATIENT=5 UNITS] [207835]
Red Blood Cells (Adult) [BLB0006] 5 UNITS For 5 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 11 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 5 UNITS For 5 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 significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina) [NO
RECENT HEMOGLOBIN/HEMATOCRIT,
UNABLE TO CALCULATE VOLUMEe] [207836]
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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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:
Page 12 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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) [NO
HEMOGLOBIN/HEMATOCRIT RESULT SINCE
LAST BLOOD ORDER, UNABLE TO
CALCULATE VOLUME] [210436]
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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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 significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=0 UNITS] [207837]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require blood at
this time because they are already above the
target hemoglobin/hematocrit level. Select a
different indication or exit the order set.
[NURCOM0022]
ONCE
Page 13 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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)
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT] [207838]
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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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 significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=2 UNITS] [207839]
Page 14 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 2 UNITS For 2 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 2 UNITS For 2 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 significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=3 UNITS] [207846]
Page 15 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 3 UNITS For 3 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 3 UNITS For 3 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 significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=4 UNITS] [207847]
calculation display removed
Page 16 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 4 UNITS For 4 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 4 UNITS For 4 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 significantly
impairing tissue O2 delivery, acute coronary
syndromes (e.g., MI, unstable angina)
[CALCULATED VOLUME FOR THIS
PATIENT=5 UNITS] [207848]
Page 17 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 5 UNITS For 5 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: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 5 UNITS For 5 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]
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): NON-
SURGICAL USE
Date Product Needed: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
Page 18 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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:
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): NON-
SURGICAL USE
Date Product Needed: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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]
Page 19 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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): NON-
SURGICAL USE
Date Product Needed: 4/25/2017
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):
CMV Negative (Heart/Lung Transplant and
Neonates up to 4 Months Only) (May be pre-
selected based on history):
Consent Status:
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:
Plasma - Adult (Single Response) [222745]
appropriate, the system will automatically suggest the appropriate number When Select indication below.
@BUCWTMSG@of units for this patient based on the indication.
units. calculator will suggest up to a maximum of 5 The
F1-Active hemorrhage or correction of
coagulopaty for INR >= 1.8 (NOT on warfarin)
[NO INR SINCE LAST PLASMA ORDER,
UNABLE TO CALCULATE VOLUME] [221715]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
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: 4/25/2017
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Page 20 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopaty for INR >= 1.8 (NOT on warfarin)
[NO RECENT INR, UNABLE TO CALCULATE
VOLUME] [221714]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
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: 4/25/2017
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopaty for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=0 UNITS] [221716]
NO ORDER RECOMMENDED: Based on this
indication, the patient does not require plasma at
this time because their INR is already <=1.8 -
Select a different indication or exit the order set.
[NURCOM0022]
ONCE
F1-Active hemorrhage or correction of
coagulopaty for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=1 UNIT] [221717]
Page 21 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Plasma (Adult) [BLB0003] 1 UNIT For 1 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
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: 4/25/2017
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 1 UNIT For 1 Occurrences, Routine,
Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopaty for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=2 UNITS] [221718]
Plasma (Adult) [BLB0003] 2 UNITS For 2 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
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: 4/25/2017
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 2 UNITS For 2 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
Page 22 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopaty for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=3 UNITS] [221719]
Plasma (Adult) [BLB0003] 3 UNITS For 3 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
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: 4/25/2017
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 3 UNITS For 3 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopaty for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=4 UNITS] [221720]
Plasma (Adult) [BLB0003] 4 UNITS For 4 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
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: 4/25/2017
Consent Status:
Page 23 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 4 UNITS For 4 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after final
plasma transfusion
F1-Active hemorrhage or correction of
coagulopaty for INR >= 1.8 (NOT on warfarin)
[CALCULATED VOLUME FOR THIS
PATIENT=5 UNITS] [221721]
Plasma (Adult) [BLB0003] 5 UNITS For 5 Occurrences, Routine
Reason for Order: F1 Active hemorrhage or
correction of coagulopathy for INR > 1.8 (NOT on
warfarin)
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: 4/25/2017
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] TRANSFUSE 5 UNITS For 5 Occurrences,
Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
phytonadione (VITAMIN K1) intraVENOUS
[800206]
10 mg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after final
plasma transfusion
F2-Invasive procedure that will begin in more
than 24 hours (on warfarin) [219278]
is not indicated.Plasma
Note: Discontinue [950016] ONCE For 1 Doses
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
Page 24 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 12 hours after
phytonadione infusion
F3-Immediate reversal of warfarin [219279]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after PCC
administration
F3-Immediate reversal of warfarin [222895]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
25 Units/kg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after PCC
administration
F3-Immediate reversal of warfarin [222894]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
35 Units/kg, Intravenous, ONCE For 1 Doses
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after PCC
administration
F3-Immediate reversal of warfarin [222896]
Plasma is not indicated.
Note: Discontinue [950016] ONCE
Discontinue warfarin
phytonadione (VITAMIN K1) intraVENOUS
[800206]
Intravenous
prothrombin complex PCC (KCENTRA) injection
kit [157782]
50 Units/kg, Intravenous, ONCE For 1 Doses
Page 25 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting today For
1 Occurrences, Routine
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? 1 hour after PCC
administration
F4-Plasmapheresis [214323]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F4 Plasmapheresis
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:
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
F5-Massive Transfusion Procedure [214326]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F6 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:
Consent Status:
Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
F6-Other [214328]
Plasma (Adult) [BLB0003] Routine
Reason for Order: F7 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:
Consent Status:
Page 26 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Plasma (Adult) [NURTRT0031] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Platelets - Adult (Single Response) [207853]
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):
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:
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: Call Blood Bank at 263-
8367 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]
Page 27 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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):
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:
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: Call Blood Bank at 263-
8367 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 surgery) [214342]
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):
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:
Page 28 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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: Call Blood Bank at 263-
8367 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):
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:
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: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
P5-Platelet dysfunction and ongoing bleeding
[214346]
Page 29 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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):
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:
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: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
P6-Massive Transfusion Procedure [214347]
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):
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:
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: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
P7-Other [214348]
Page 30 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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):
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:
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: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
Cryoprecipitate - Adult (Single Response) [207854]
indication below.Select
C1-Fibrinogen deficiency (< 100 mg/dL) [214349]
Cryoprecipitate (Adult) [BLB0005] Routine
Reason for Order: C1 Fibrinogen deficiency (< 100
mg/dL)
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:
Consent Status:
Fibrin Glue, mLs Needed:
Transfuse Cryoprecipitate (Adult) [NURTRT0032] Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
C2-Factor XIII deficiency [214350]
Page 31 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Cryoprecipitate (Adult) [BLB0005] Routine
Reason for Order: C2 Factor XIII deficiency
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:
Consent Status:
Fibrin Glue, mLs Needed:
Transfuse Cryoprecipitate (Adult) [NURTRT0032] Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
C3-Massive Transfusion Procedure [214351]
Cryoprecipitate (Adult) [BLB0005] Routine
Reason for Order: C3 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:
Consent Status:
Fibrin Glue, mLs Needed:
Transfuse Cryoprecipitate (Adult) [NURTRT0032] Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
C4-Other [214352]
Cryoprecipitate (Adult) [BLB0005] Routine
Reason for Order: C4 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:
Consent Status:
Fibrin Glue, mLs Needed:
Page 32 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Cryoprecipitate (Adult) [NURTRT0032] Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
Red Blood Cells - Pediatric (Single Response) [214402]
indication below.Select
PR1-(Patient younger than 4 months) Acute
blood loss or anticipated surgical blood loss
[214359]
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):
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:
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):
Page 33 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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%) [214360]
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):
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:
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 poor oxygenation [214361]
Page 34 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
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:
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 synchronized intermittent
mandatory ventilation with FiO2 > 40%,
congenital heart disease, and/or prematurity
[214362]
Page 35 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
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:
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 36 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
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:
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 37 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
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:
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 ventilation or congenital heart disease
[214363]
Page 38 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
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:
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 39 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
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:
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 40 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
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:
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 41 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
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:
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):
Plasma - Pediatric (Single Response) [214403]
indication below.Select
PF1-Elevated INR with active bleeding or
anticipated major surgery/invasive procedure
[214369]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF1 Elevated INR with active
bleeding or anticipated major surgery/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:
Consent Status:
Page 42 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF2-Pump prime in pediatric open heart surgery
as appropriate for neonates and lower weight
pediatric patients [214371]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF2 Pump prime in pediatric
open heart surgery as appropriate for neonates and
lower weight pediatric 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:
Consent Status:
Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF3-Replacement therapy for hemostatic factor
deficiencies if concentrate not available [214373]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF3 Replacement therapy for
hemostatic factor deficiencies if concentrate not
available
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:
Consent Status:
Page 43 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF4-Disseminated intravascular coagulation with
active bleeding [214374]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF4 Disseminated intravascular
coagulation with active 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:
Consent Status:
Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF5-Immediate reversal of warfarin effect for
emergency surgery or active bleeding (in
combination with vitamin K) [214375]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF5 Immediate reversal of
warfarin effect for emergency surgery or active
bleeding (in combination with vitamin K)
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:
Consent Status:
Page 44 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF6-Massive Transfusion Procedure [214376]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF6 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:
Consent Status:
Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
PF7-Other [214377]
Plasma (Pediatric) [BLB0010] Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order: PF7 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:
Consent Status:
Page 45 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Plasma (Pediatric) [NURTRT0037] Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Call UWHC Blood Bank at
(608) 263-8367 or The American Center Lab at
(608) 234-6600 as appropriate 30-60 minutes
before transfusion to prepare products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Platelets - Pediatric (Single Response) [214404]
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):
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:
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: Call Blood Bank at 263-
8367 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 46 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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):
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:
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: Call Blood Bank at 263-
8367 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]
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):
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:
Page 47 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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: Call Blood Bank at 263-
8367 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):
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:
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: Call Blood Bank at 263-
8367 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]
Page 48 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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):
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:
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: Call Blood Bank at 263-
8367 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]
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):
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:
Page 49 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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: Call Blood Bank at 263-
8367 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]
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):
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:
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: Call Blood Bank at 263-
8367 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]
Page 50 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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):
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:
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: Call Blood Bank at 263-
8367 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):
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:
Page 51 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@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: Call Blood Bank at 263-
8367 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]
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):
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:
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: Call Blood Bank at 263-
8367 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]
Page 52 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

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):
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:
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: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Cryoprecipitate - Pediatric (Single Response) [214313]
indication below.Select
PC1-Active bleeding OR anticipated major
surgery/invasive procedure (e.g., ECMO) with
fibrinogen < 100 mg/dL or dysfibrinogenemia
[214315]
Cryoprecipitate (Pediatric) [BLB0012] Routine
Reason for Order: PC1 Active bleeding OR
anticipated major surgery/invasive procedure (e.g.,
ECMO) with fibrinogen < 100 mg/dL or
dysfibrinogenemia
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:
Consent Status:
Page 53 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested
dose: 1 Unit/10 kg body weight. If patient weighs
less than 10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
PC2-Factor XIII deficiency [214317]
Cryoprecipitate (Pediatric) [BLB0012] Routine
Reason for Order: PC2 Factor XIII deficiency
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:
Consent Status:
Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested
dose: 1 Unit/10 kg body weight. If patient weighs
less than 10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
PC3-Massive Transfusion Procedure [214400]
Cryoprecipitate (Pediatric) [BLB0012] Routine
Reason for Order: PC3 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:
Consent Status:
Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested
dose: 1 Unit/10 kg body weight. If patient weighs
less than 10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
PC4-Other [214401]
Page 54 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Cryoprecipitate (Pediatric) [BLB0012] Routine
Reason for Order: PC4 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:
Consent Status:
Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested
dose: 1 Unit/10 kg body weight. If patient weighs
less than 10 kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-
8367 30-60 minutes before transfusion to prepare
products.
Run Over:
Laboratory (Post Infusion)
Laboratory [12025]
HEMATOCRIT [HCT] CONDITIONAL - RN COLLECT, Starting tomorrow
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, Starting tomorrow
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
PROTHROMBIN TIME/INR [PT] CONDITIONAL - RN COLLECT, Starting tomorrow
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 plasma
Medications - Pre-medications - NOTE: Order for patients with previous
reaction to transfusion
Analgesics (Single Response) [12024]
acetaMINOPHEN (TYLENOL) tab [34149] 650 mg, Oral, ONCE PRN For 1 Doses, pain,
premedication for blood product
Premedication for blood product
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, ONCE PRN For 1 Doses, pain/fever,
premedication for blood product
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [800005]
15 mg/kg, Oral, ONCE PRN For 1 Doses, pain/fever,
Premedication for blood product
Premedication for blood product
NOTE: Suggested dose 15 mg/kg (Maximum 650
mg/dose)
Antihistamines (Single Response) [13510]
Page 55 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

diphenhydramine (BENADRYL) cap [36791] 25 mg, Oral, ONCE For 1 Doses
Premedication for blood product
diphenhydramine (BENADRYL) cap [36791] 50 mg, Oral, ONCE For 1 Doses
Premedication for blood product
diphenhydramine (BENADRYL) injection 25 mg
[800106]
25 mg, Intravenous, ONCE For 1 Doses
Premedication of blood product
diphenhydramine (BENADRYL) injection 50 mg
[800106]
50 mg, Intravenous, ONCE For 1 Doses
Premedication for blood products
Steroids (Single Response) [13511]
dexamethasone (DECADRON) intraVENOUS
[800037]
4 mg, Intravenous, ONCE For 1 Doses
Premedication for blood products
Page 56 of 56
Printed by O'BRIEN, RYLEY P [RPO249] at 4/25/2017 9:40:04 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org