PRACTITIONER PRE-PRINTED ORDERS
Ordering of Red Blood Cells – ADULTS
(PILOT)
Addressograph
To complete the order form, fill in required blanks and/or check
the appropriate boxes.
Bulleted items will be initiated automatically.
To delete orders, draw one line through the item and initial.
Allergies: No  Yes  (list allergies below)
Posted
Initial
Patient Weight
Est._____kg Actual ______kg
ORDERS AND SIGNATURE
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Streamlined Red Blood Cell (RBC) Ordering
Strong evidence suggests that in hemodynamically stable, non-bleeding patients, a hemoglobin threshold
of 70 g/L (or 80 g/L in acute coronary syndromes) can decrease transfusion requirements and avoid
adverse outcomes. Single unit transfusions are usually preferable.
Recent studies suggest that using intravenous iron to replace lost stores and speed erythropoiesis may be
efficacious in the asymptomatic, non-bleeding patient. Consider using intravenous iron if appropriate. Consider
B12/folate and erythropoietic stimulating agent. See PPO 290 for iron sucrose infusion.
 Informed consent for transfusion obtained and documented (RQHR 370/254 or 1163 - top box)
(please attach to outpatient orders)
Orders
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Uncrossmatched (physician signature required; see below)
STAT
Routine
Special requirements for oncology/immunosuppressed patients (see Appendix):_________________
_________________________________________________________________________________
Please indicate the reason for transfusion:
 Acute blood loss (hemoglobin less than 70) and tachycardia + hypotension
 Anemia (hemoglobin less than 80) and active ischemia (ECG changes and tachycardia/hypotension)
 Patient is undergoing active treatment anticipated to cause significant blood loss
 Other: ___________________________________________________________________________
 Specify the number of units needed: _____
 Record the most recent lab value of hemoglobin: _____ g/L
 If more than 1 unit needed, give reason: ____________________________________________
Infusion rate:
 Transfuse 1 unit at 125 mLs/hour or over _____ hours (e.g., 1 unit over 2-3 hours, maximum 4 hrs)
 Transfuse _____ units, each over _____ hrs
 furosemide _____ mg IV x 1 dose prior to transfusion in euvolemic patients (consider post-transfusion dose
as clinically indicated)
 Specify post-transfusion blood work and timing: _______________________________________
USE OF UNCROSSMATCHED DONOR RED CELLS
I am aware the risk of transfusion of uncrossmatched donor red blood cells is greater than the risk of fully
crossmatched donor red blood cells. It is my clinical judgment, that the risk of awaiting fully crossmatched
donor red blood cells is greater than the risk of administering uncrossmatched donor red blood cells.
Physician Signature: _________________________________
Date: __________________
(DD/MM/YYYY)
CALL RGH TRANSFUSIONS (306)766-4474 AND FAX FORM TO (306)766-4004
WHEN UNCROSSMATCHED RBCs required
Date & Time
Practitioner Signature:
Practitioner Name (printed):
Version: December 2016
Approved by: Department of Laboratory Medicine, Section of Transfusion Medicine
Revision Date: December 2019
Form No.: PP-601
PRACTITIONER PRE-PRINTED ORDERS
Ordering of Red Blood Cells – ADULTS
PILOT
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Appendix A
Special Requirement
Irradiated Cellular
Blood Components
CMV Safe Cellular Blood
Components
Eligible Patients

Allogenic stem cell/bone marrow transplant recipients (from start of conditioning
chemotherapy, for life after transplant)
 Autologous stem cell/bone marrow transplant recipients (from 7 days before the
start of stem cell mobilization, until 6 months post-transplant)
 Allogeneic stem cell donors (7 days prior to collection and during the collection
process only)
 Hodgkin’s lymphoma, for life
 Patient receiving or who have receive the following (for life, from the time of drug
initiation):
 Anti-thymocyte globulin (ATG)
 Alemtuzumab (Campath)
 Bendamustine
 Cladibine
 Clofarabine
 Deoxycoformicin
 Fludarabine
 Pentostatin
 Congenital T-cell immune deficiency (DiGeorge syndrome, SCID)
 Directed donations – always irradiated by Canadian Blood Services prior to issue
 HLA matched components – always irradiated by Canadian Blood Services prior
to issue
All blood components in Canada have undergone pre-storage leukoreduction and are
considered “CMV safe”. Transfusion of leukoreduced plus CMV seronegative blood
components has not been identified to provide additional protection against
transfusion-transmitted CMV.
Version: December 2016
Approved by: Department of Laboratory Medicine, Section of Transfusion Medicine
Revision Date: December 2019
Form No.: PP-601