Patient Name: ________________________________________
Blood Bank
Transfusion Medicine and Cellular Therapy
Mount Sinai Medical Center
One Gustave L. Levy Place
New York, NY 10029
-- Please PRINT or attach patient label --
MRN: _______________________________________________
Unit Location: ___________________
Tube Station #
Date / Time of phone call:
_______________________________
Emergency Blood Release – Please call 4-6101 to notify Blood Bank -- ask for
“Emergency Release”, specify type of blood product, and give patient name and MRN
Emergency Packed Red Cell Release-
I certify that release of blood without complete crossmatch and/or ABO typing is clinically
indicated by the emergency nature of the patient’s condition. I understand that the Blood
Bank will perform routine compatibility and crossmatch testing as soon as possible and will
immediately report any incompatibility to me.
WARNING: STOP TRANSFUSION IMMEDIATELY IF NOTIFIED BY BLOOD BANK OF
CROSSMATCH INCOMPATIBILITY ISSUE
Uncrossmatched Blood

MD Signature: ____________________ Dict. Code/License: ___________
Reason for Emergency Transfusion: __________________________________
Blood Bank Use Only:
At the time of release, the prbc units were:
❑ O neg uncrossmatched before group and Rh
❑ Group specific uncrossmatched before complete workup
Order
Blood
Availability
Blood Bank
Provides
2 UnXM
prbc
Immediate
2 units O negative,
uncrossmatched prbc
4 UnXM
prbc
Immediate
4 units O negative,
uncrossmatched prbc
Emergency Platelets for ASA/Plavix Reversal
(CNS bleed/trauma or Code Stroke only)
❑ Incompatible due to antibody before complete workup
Platelets
Only
Unit Numbers Released (see attached):
Immediate
1 single donor platelet
( =6 units plts)
Emergency Plasma for Coumadin Reversal
(CNS bleed/trauma or Code Stroke only)
Plasma
Only
Immediate
2 units plasma
(pre-thawed)
Emergency Clotting Factor for Coumadin
Reversal or known Clotting Factor Deficiency Patient
(CNS bleed/trauma or Code Stroke only)
Specify Blood Derivative Type:
Specify Dose:
Neonatal / Pediatric Emergency Transfusion
Specify Blood Products / Derivative:
Tech ID: see SoftBank / Reviewed by BB Medical Director/Designee: _______________________ Date: _______________
Specify amount in mL:
Massive Transfusion Protocol – Call 4-6101 to notify Blood Bank -- ask for
“Massive Transfusion Pack” and give patient name and MRN
I certify that release of blood without complete crossmatch and/or ABO typing is clinically
indicated by the emergency nature of the patient’s condition. I understand that the Blood
Bank will perform routine compatibility and crossmatch testing as soon as possible and will
immediately report any incompatibility to me.
I further certify that the clinical condition of this patient warrants use of the massive
transfusion protocol, with immediate need for plasma and/or platelet.
WARNING: STOP TRANSFUSION IMMEDIATELY IF NOTIFIED BY BLOOD BANK OF
CROSSMATCH INCOMPATIBILITY ISSUE
Massive Transfusion Protocol Intensity Level – Round 1

Blood Bank Provides:
4 packed red cell units
4 plasma
1 single donor platelet ( = 6 units of platelets)
MD Signature: ______________________ Dictation Code: ____________
Reason for Massive Transfusion: ______________________________________
Blood Bank Use Only:
At the time of release, the prbc units were:
❑ O neg uncrossmatched before group and Rh
❑ Group specific uncrossmatched before complete workup
❑ Incompatible due to antibody before complete workup
Unit Numbers Released (see attached):
Massive Transfusion Protocol – After Round 1:
1. Send CBC, PT/PTT and Fibrinogen level to follow for
coagulopathy / modify transfusions as needed.
2. Suggested Ratio for Replacement of Ongoing Blood Loss:
4 rbc: 4 plasma: 1 single donor platelet
3. If fibrinogen <100 mg/dL, order cryoprecipitate, pooled x 2
doses
Tech ID: see SoftBank / Reviewed by BB Medical Director/Designee: _______________________ Date: _______________
BB #24 Draft
Do not chart / Blood Bank use only- Please have physician sign/complete highlighted area and return this form to Blood Bank, tube station # 114.