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Download 57.308 - Harvard Medical School Fellowship Program in Transfusion
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Adapted for Joint Program in Transfusion Medicine (JPTM) from: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/ Approved JPTM: 01/20/2017 NHSN Additional Reaction Data Form: Allergic Transfusion Reaction Patient Information *Patient MRN: ___________________ Last Name: ___________________ First Name: ____________________ Patient Medical History (complete Part 1 and Part 2) Part 1 List at least one admitting diagnosis. (Use ICD-10 Diagnostic codes/descriptions) Code: ______________ Description: __________________________________________________ Code: ______________ Description: __________________________________________________ Code: ______________ Description: __________________________________________________ Part 2 Select/list at least one patient underlying indication for transfusion. Code: R58 Description: Hemorrhage, Not Classified Elsewhere Code: D696 Description: Thrombocytopenia, Unspecified Code: D689 Code: D649 Code: D709 Description: Coagulation defect, Unspecified Description: Anemia, Unspecified Description: Neutropenia, Unspecified Code: _____________ Description: ______________________________________________ Reaction Details (complete all information) *Date reaction occurred: ____/____/____ *Transfusion Start Time: __ __:__ __ *Time reaction occurred: __ __:__ __ *Transfusion End Time: __ __:__ __ Time unknown Investigation Results Allergic reaction, including anaphylaxis Case Definition Check all that apply that occurred during or within 4 hours of cessation of transfusion: Conjunctival edema Edema of lips, tongue and uvula Localized angioedema Hypotension Erythema and edema of the periorbital area Respiratory distress; bronchospasm Urticaria Generalized flushing Maculopapular rash Pruritus None of the above Other signs and symptoms: (check all that apply) Generalized: Chills/rigors Cardiovascular: Cutaneous: Shock Fever Nausea/vomiting Jaundice Hemolysis/Hemorrhage: Disseminated intravascular coagulation Positive antibody screen Pain: Abdominal pain Renal: Hematuria Respiratory: Bilateral infiltrates on chest x-ray Hypoxemia Back pain Hemoglobinemia Flank pain Infusion site pain Hemoglobinuria Oliguria Cough Shortness of breath Other: (specify) ________________________________________________________________ continued>> Adapted for JPTM on 2017.01.20 using: CDC 57.308 R0, v8.6 Page 1 of 2 Adapted for Joint Program in Transfusion Medicine (JPTM) from: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/ Approved JPTM: 01/20/2017 Severity (select only one): Did the patient receive or experience any of the following? (Response definitions listed in table of instructions) Symptomatic treatment only Hospitalization, inlcuding prolonged hospitalization Life-threatening reaction Disability and/or incapacitation Congenital anomaly or birth defect(s) of the fetus Other medically important conditions Death Unknown or not stated Imputability (select only one): Which best describes the relationship between the transfusion and the reaction? No other evidence of environmental, drug or dietary risks. There are other potential causes present that could explain acute hemolysis, but transfusion is the most likely cause. Other present causes are most likely, but transfusion cannot be ruled out. Evidence is clearly in favor of a cause other than the transfusion, but transfusion cannot be excluded. There is conclusive evidence beyond reasonable doubt of a cause other than the transfusion. The relationship between the adverse reaction and the transfusion is unknown or not stated. When did the reaction occur in relation to the transfusion? Occurred during or within 2 hours of cessation of transfusion. Occurred 2 - 4 hours after cessation of transfusion. Did the same reaction occur after the transfusion was restarted (rechallenge)? Yes No No, Not Restarted Patient Treatment *Did the patient receive treatment for the transfusion reaction? NO (go to Outcome) YES, continue below If yes, select treatment(s): Check all that apply Medication (Select the type of medication) Antipyretics Antihistamines Inotropes/Vasopressors Bronchodilator Diuretics Intravenous Immunoglobulin Antithymocyte globulin Intravenous steroids Cyclosporin Corticosteroids H1 receptor blockers Antibiotics Other Volume resuscitation (Intravenous colloids or crystalloids) Respiratory support (Select the type of support) Mechanical ventilation Noninvasive ventilation Oxygen Renal replacement therapy (Select the type of therapy) Hemodialysis Peritoneal Continuous Veno-Venous Hemofiltration Phlebotomy Other Specify: ____________________________________________________________ Outcome (select only one) *additional details warranted for this Outcome. Outcome: Death* Major or long-term sequelae Adapted for JPTM on 2017.01.20 using: CDC 57.308 R0, v8.6 Minor or no sequelae Not determined Page 2 of 2
