PLACE LABEL HERE
BLOOD COMPONENT TRANSFUSION - Neonatal
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
DIAGNOSIS: _____________________________________ PT WEIGHT: _____________ kg
 The minimal effective dose of all blood components should be used.
 BLOOD BANK PHONE: 678-312-4516 (Lawrenceville)
 Blood component consent form signed
TRANSFUSION ORDER (TYPE AND AMOUNT): ______________________________
Request for special red cell products: Blood Needs to be Irradiated, Washed, and CMV Negative. Blood Unit to less than
7 days old when released (Lab to verify with Provider if Blood > 7 days old may be released).
INDICATION: Check off at least one indication for each type of blood component ordered.
Packed Red Cells - Most recent hemoglobin ______ g/dL or hematocrit ____%
A transfusion of 10 ml/kg should increase the hemoglobin by approximately 3 g/dL & the hematocrit by 7%
 Emergency Released Blood
 Hematocrit < 20% or hemoglobin < 6.5 g/dL- Infant asymptomatic with Reticulocyte Count < 2%
 Hematocrit < 22% or hemoglobin < 7.5 g/dL- With One of following Criteria

  Tachycardia ≥ 24 hours (HR > 180)
 Doubling of O2 Requirement on NC
 Metabolic Acidosis pH < 7.2
 Weight Gain < 10 g/kg/day over a 4 day period on ≥ 120 kcal/kg/day
 Surgery within 72 hours
 Hematocrit < 25% or Hemoglobin < 8.5 g/dL- Minimal Cardiopulmonary Disease
 HFOV PaW < 10 cm H2O and/or FiO2 < 40
 Conventional Ventilator PaW < 8 cm H20 and/or FiO2 < 40 %
 Non Invasive Respiratory Support PEEP < 6 cm H2O and FiO2 < 40 %
 On Dopamine < 10 mcg/kg/min or equivalent vasopressor and/or need for saline bolus
 Hematocrit < 35% or Hemoglobin < 11.5 g/dL- Moderate to Severe Cardiopulmonary Disease
 HFOV PaW ≥ 10 cm H2O and/or FiO2 ≥ 40
 Conventional Ventilator PaW ≥ 8 cm H20 and/or FiO2 ≥ 40 %
 Non Invasive Respiratory Support PEEP ≥ 6 cm H2O and FiO2 ≥ 40 %
 On Dopamine ≥ 10 mcg/kg/min or equivalent vasopressor and/or need for saline bolus
 Hypovolemic Shock associated with suspected acute blood loss
 Hematocrit > 40 % or Hemoglobin > 13 g/dL with Severe and Labile Cardiopulmonary Disease
Platelets - Most recent platelet count ______________/cc3

A 10 ml/kg dose of platelets should increase the platelet count by 50,000/cc3
 Platelet count < 100,000/cc3 Actively bleeding neonate and who is clinically unstable (Need for respiratory or vasopressor
support)
 Platelet count < 50,000/cc3 – Non-bleeding or sick neonate or need for invasive procedure within 72 hours
 Platelet count < 30,000/cc3- Non-bleeding stable neonate
 Platelet 50% Serial Decline in 24-48 hours with known factors that predispose to thrombocytopenia and previously
documented
 Platelet Count of > 150,000/ cc3 – Specify Factors: _________________________
Fresh Frozen Plasma - Most recent coag. studies: PT _______ sec PTT _______ sec
A dose of 10 - 15 mL/kg is usually adequate to correct a coagulopathy
 Severe Clotting Factor Deficiency with Bleeding
 Severe Clotting Factor Deficiency and Invasive Procedure
 Vitamin K deficiency with Bleeding
 Severe and ongoing hemorrhage in an unstable neonate with undocumented PT/PTT values or values not reflective of
coagulopathy
______________
_____________
*1-38533*
1
_________________________________
FORM 1-38533 INITIATED 05/2015
___________
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PLACE LABEL HERE
BLOOD COMPONENT TRANSFUSION - Neonatal
ORDERS
Date
Time
*1-38533*
1
Physician Signature
FORM 1-38533 INITIATED 05/2015
PID Number
Page 1 of