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Date Name MRN, DOB Location Mount Sinai Hospital New York, NY 10029 APHERESIS UNIT (212) 241-6104 Physician/Service THERAPEUTIC APHERESIS ORDER SET Patient Diagnosis: _________________________ Patient Age: _______ Referring MD____________________ Vital sign frequency: Routine q1° Location of procedure: Apheresis Unit Other: ______________ Apheresis instrument: Spectra Other_______________ Apheresis Schedule/Frequency: Continuous _____________________________________ Plasmapheresis: Plasma volumes to exchange ___________ Replacement fluid: Red cell exchange: Cytoreduction: Replacement fluid: Anticoagulant: Patient: 5% Albumin___________% 0.9% NaCl ___________ % FFP____________ % Cryo-poor plasma ________% PRBC volumes to exchange ___________ Average Hct of red cell units_______ End point patient Hct__________% Desired FCR___________% WBC Target cell count: Fluid balance desired: ___________ Platelets _________________ Blood volumes for processing: ______________ 5% Albumin______% ACD-A 0.9% NaCl ___________ % FFP____________ % Heparin: ________U/500 mL ACD-A and AC: WB ratio ___________ Weight ____________ lb / kg Safe ECV _________________ mL Height ___________ in / cm Red cell prime: TBV ______________mL Undiluted Diluted Hb/Hct ________ Plts_________ WBC_________ PT/aPTT ___________Serum Ca _______ LFTs _______ Labs to order: Pre______________________________________ □ADMTS-13 (vWFPA) □T & S Post______________________________________ Medications: ______ mL 10% Calcium gluconate (94 mg/mL) in 150mL NS for continuous drip throughout procedure Benadryl IV/po ________mg Tylenol po ___________mg Heparin dwell ________units per lumen. Solu-Cortef/Medrol IV_______mg Sterile dressing change, as needed. Special instruction/comments: ________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Attending Signature _______________________________ Date/Time ____________________ Nurse’s Signature _________________________________ Date/Time____________________ APH 507v2 Page 1 of 2 Physician’s Additional Instructions Date/Time____________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ 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