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Red Cell Transfusion 
Consider: Risks/Benefits/Alternatives/Single Unit

Indications:           Hb g/L Amount: unit(s)/mLs

Associated factors(s): please circle

Patient: haemodynamically unstable / stable / chronically transfused 

Bleeding: none / acute / critical bleeding protocol activated / chronic / ongoing / anticipated / 

GI / Surgical / PPH / other type

Ischaemia: acute coronary syndrome / acute CVA, TIA / PHx IHD / PHx CVA, TIA / NIL

Symptoms: dyspnoea / dizziness / ischaemic chest pain / cardiac failure / fatigue

other symptoms:

Other transfusion reason(s): state

Obtain &amp; document informed consent: MO name

  Written patient information provided* Pager  date

 Signature  time

IF IN DOUBT, ASK. Guidelines on Transfusion Practice available at www.blood.gov.au 
*See intranet link to BloodSafe Pt and clinical resources 

BloodSafe-TP-L3-401 MO sticker v1.2 06/15

Affix in case-notes 
Verify correct patient identity

In stable, normovolaemic adult inpatients WITHOUT clinically significant bleeding, transfuse 1 unit 
then reassess the pt. In pts with iron deficiency anaemia (IDA), iron therapy is REQUIRED even if 
transfusion is needed: see MJA update on IDA, Nov 2010

Red Cell Transfusion Indications
Obtain and document informed consent

Indications:    Hb........................ g/L    Reason(s).......................................................................................................
Tick all boxes that apply (including multiple under each heading if they apply)

Bleeding ( ):
 q Critical bleeding
 q Acute
 q Anticipated
 q Ongoing
 q PPH
 q GI
 q Surgical
 q None
 q Other .................................

Patient/symptoms ( ):
 q Haemodynamically unstable
 q Stable
 q Chronically transfused
 q Cardiac failure
 q Dyspnoea
 q Dizziness
 q Fatigue
 q Ischaemia chest pain
 q Other .................................

Ischaemia  ( ):
 q Acute coronary syndrome
 q Acute CVA or TIA
 q PHx IHD
 q PHx CVA or TIA
 q None
 q Other (comment) ........................
.......................................................
.......................................................

In stable, normovolaemic adult inpatients WITHOUT clinically significant bleeding, transfuse 1 unit then reassess.
In patients with iron deficiency anaemia, iron therapy is required even if transfusion is needed.

 q Written patient information provided*
MO name................................... Sign................................... Pager......................... Date ...../...../..... Time .....:.....

Designation...............................................................................................................................................................

Refer to intranet for Health Service critical bleeding protocols, links to national 
transfusion guidelines and BloodSafe consumer* and clinical resources. BloodSafe-TP-L3-401 MO sticker v1.3 09/19

Affix in medical record


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