Suspected Delayed Transfusion Reaction

Trident Health System
Suspect Delayed Transfusion Reaction form
Patient Name __________________DOB ________ MR # _________________ Physician _______________
Patient Location ____________ BB Wristband # __________ Diagnosis ______________________________
Reason for DTR investigation:
 Blood Bank Serological findings: New antibody formation in current specimen that is within 3 weeks of
previous specimen lacking the antibody. Possible anamnestic antibody response to recently transfused
RBC’s.
 Patient MD request
Legend: Abbreviations: ABSC = Antibody Screen, ABID = Antibody ID, DAT = Direct Antiglobulin Test, n/a = not applicable, np = not performed
Reference ranges / units: Dipstick blood = neg, RBC’s/hpf = none, Total Bili = <1.0 mg/dL, Direct Bili = 0.0-0.3 mg/dL, Indirect Bili = 0.0-0.8
mg/dL, Haptoglobin = 50-370 mg/dL
Pre-transfusion Blood Bank Testing:
Date _________________ ABSC __________Repeat ABSC ___________ABID ___________ DAT_________
Recent transfusions (3 weeks)
Date _________________ # RBC’s _________________Date ____________ # RBC’s _________________
Date _________________ # RBC’s _________________ Date ____________ # RBC’s ________________
Pre-transfusion lab testing (see legend for units and reference ranges)
Urinalysis: Date(s) __________________ Dipstick Blood _____________ RBC’s /hpf _____________
Bilirubin: Date(s) ________________Total _____________Direct _____________ Indirect ______________
Post-transfusion / current specimen Blood Bank Testing:
Date _________________ ABSC _______________ ABID ______________________________________
DAT ________________Elution ___________________________ Antigen Typing ___________________
Other / comments: _____________________________________________________________________
_____________________________________________________________________________________
Post-transfusion lab testing
Urinalysis: Date(s) __________________ Dipstick Blood __________ RBC’s /hpf _____________
Bilirubin: Date(s) ________________Total _________Direct ________ Indirect _________
Haptoglobin (if indicated by Medical Director as below) Date: ______________ Result ____________
Other / comments:__________________________________________________________________________
_________________________________________________________________________________________
Initial Notification to BB Medical Director/designee_____________Date _______ Time______ Tech______
Haptoglobin indicated? ________ Other testing indicated? __________BB MD notified Patient MD? _________
Comments ________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Date sent for final BB Medical Director review ___________ Tech: ________
Blood Bank Medical Director Review ________________________________ Date __________
Comments _________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Copy to: Floor __ Medical Records __ Supervisory Review ______________ Date _________
DHTR form.022208
TMC
Revised 022208

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