Sindh Blood Transfusion Authority

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Report Transfusion

Official Portal

Complaint

PRODUCT INFORMATION

Product type:

Donor Identification Information:

Group:

Date of Issue:

REPORTING FACILITY INFORMATION

Date of Submission:

Name of the Reporting Facility:

Name of the Person Filling Out Form:

Title:

Facility Address:

Telephone Number:

Email:

PATIENT/RECIPIENT INFORMATION

Electronic Medical Record #:

Name (optional):

Age:

Contact Number:

Was this product received in good condition?

Yes

Valid Expiry?

Yes

Valid Group?

Yes

Transfusion Started:

Date:

Time:

Transfusion Stopped:

Date:

Time:

Volume Transfused (approximate in ml):

Did any reaction happen?

Yes

Reaction Vital Signs

Date:	Pre-Transfusion	During Reaction	Post-Reaction
Time
Temperature
Blood Pressure (Systolic)	mm Hg	mm Hg	mm Hg
Blood Pressure (Diastolic)	mm Hg	mm Hg	mm Hg
Pulse	bpm	bpm	bpm
Respiratory Rate	rpm	rpm	rpm
O2 Sat	%	%	%

Symptoms/Signs at Time of Reaction - Check all that apply.
[1] Allergic/Anaphylactic | [2] TRALI | [3] TACO | [4] Septic Transfusion Reaction

Suspected Adverse Reaction: Assign priority if more than one possibility*

Allergic/Anaphylaxis†

Transfusion-related acute lung injury (TRALI)‡

Septic transfusion reaction§

INSTRUCTIONS:

Transfusion should be started within 30 minutes of the issuance.
If not transfused, the blodd should not be kept in home refrigerators.
Patient after transfusion should be observed for any side effects for 24 hours.
If a reaction occurs, a fresh sample for blood grouping and cross-match should be sent to laboratory for cross verification.

Abdominal pain/cramps[1,4]	Dyspnea [1, 2, 3, 4]	Loss of consciousness[1]
Angioedema[1]	Edema – pulmonary[2,3]	Nausea/Vomiting [1,4]
Anxiety[1]	Edema – Pedal[3]	Oliguria[4]
Arrythmia[1]	Erythema[1]	Orthopnea[3]
Back pain[4]	Fever [2,4]	Pain at infusion site[4]
Cardiac arrest[1]	Flushing[1]	Pruritis[1]
Chest pain[4]	Headache [3,4]	Shock [1,4]
Chest tightness [1,3]	Hoarseness/Stridor[1]	Substernal pain[1]
Chills/Rigors[4]	Hypertension [2,3]	Tachycardia[1,2,3,4]
Cough [3,4]	Hypotension [1, 2,4]	Tachypnea[2,3]
Cyanosis [1, 2,3]	Hypoxemia [2,3]	Urticaria[1]
Diarrhea[1]	Impending doom[1]	Wheezing [1,4]
DIC	Jugular venous distension[3]	Widened pulse pressure[3]