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Please complete this form electronically and press the submit button at the bottom – this will automatically send an email to nbl@nhsbt.nhs.ukAny reaction which involves bacterial contamination as a differential diagnosis must be discussed as soon as possible with the duty NHSBT consultant for patients, in case other components from the same blood donation require recall. The Duty Consultant can be contacted via the NHSBT Hospital Services Department at your local NHSBT centreReferring Hospital: FORMTEXT ?????Donation number of implicated component: FORMTEXT ?????Local NHSBT centre: FORMTEXT ?????Name of duty NHSBT consultant contacted by the hospital: FORMTEXT ?????Name of person reporting the reaction: FORMTEXT ????? Date: FORMTEXT ????? Contact email address: FORMTEXT ?????Patient detailsDetails of implicated componentSurname: FORMTEXT ?????Type of blood component transfusedForename: FORMTEXT ????? FORMCHECKBOX Red cells FORMCHECKBOX Platelets FORMCHECKBOX FFP FORMCHECKBOX OtherDOB: FORMTEXT ?????Hospital number: FORMTEXT ?????Details of transfusion reactionDate and time transfusion of implicated unit started: FORMTEXT ?????Time from start of transfusion to onset of symptoms: FORMTEXT ?????Approximate volume transfused: FORMTEXT ?????Patient’s underlying diagnosis and reason for transfusion: FORMTEXT ?????Patient’s symptoms (please tick all that apply) FORMCHECKBOX Pyrexia FORMCHECKBOX Headache FORMCHECKBOX Pain at iv site FORMCHECKBOX Back pain FORMCHECKBOX Chills or rigors FORMCHECKBOX Tachycardia FORMCHECKBOX Hypotension FORMCHECKBOX Loin pain FORMCHECKBOX Breathlessness FORMCHECKBOX Wheeze FORMCHECKBOX Productive cough FORMCHECKBOX Nausea or vomitingFurther details: FORMCHECKBOX Rash FORMCHECKBOX Urticaria/hivesobservations before transfusionTemp FORMTEXT ????? Pulse FORMTEXT ????? BP FORMTEXT ?????observations at time of transfusion reactionTEMP FORMTEXT ????? Pulse FORMTEXT ????? BP FORMTEXT ?????Management of transfusion reactionWas the patient on antibiotics at the time of the reaction? YES FORMCHECKBOX NO FORMCHECKBOX If YES, which antibiotics: FORMTEXT ?????Were blood cultures taken from the patient? YES FORMCHECKBOX NO FORMCHECKBOX If YES, where were they taken from: FORMCHECKBOX Peripheral vein FORMCHECKBOX Central line Please send the results to nbl@nhsbt.nhs.ukWas the patient given antibiotics to treat the reaction? YES FORMCHECKBOX NO FORMCHECKBOX If YES, which antibiotics? FORMTEXT ?????Was the implicated unit cultured by your local microbiology laboratory? YES FORMCHECKBOX NO FORMCHECKBOX If YES, please forward these results when available to nbl@nhsbt.nhs.ukWhat was the storage temperature of the unit before transport FORMCHECKBOX Ambient FORMCHECKBOX 2-8?CEnquiries should be directed to the Blood Components section of the National Bacteriology Laboratory, NHSBT Colindale Centre on 020 8957 2959 or 020 8957 2962 or email nbl@nhsbt.nhs.uk1. Return the implicated unit(s) to your local NHSBT Hospital Services Department in the labelled 3 litre biobottle provided specifically for this purpose. This will then be forwarded to the National Bacteriology Laboratory at Colindale2. The returned unit(s) must be adequately sealed with appropriate pack closure to prevent leakage and contamination.3. If possible unit(s) should be stored and transported at 2°C-8°C. Select ‘enable macros’ in the yellow bar when first opening the document and then complete the form, press the SUBMIT button and a message will appear select ‘allow’. ................
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