Clinical Practice Guideline

Fresh Warm Whole Blood (FWB)

Definition: Blood that has been drawn recently (within 24 hours) but NOT separated into its components. Contains red blood cells, plasma, clotting cascade actors, and platelets. Indications: Coagulopathy o trauma or acute blood loss in the austere setting when blood component(!BCs, ""#, #latelets, C!$O) therapy is una%ailable 1. Background Whole blood has been used extensively in military conflicts since World War I to resuscitate casualties. Indications for whole blood in the civilian setting are limited due to the wide available of fractionated components (R Cs! ""P! platelets! cryo# derived from whole blood and provided for specific deficits (e.g.! R Cs for anemia! ""P to replace lost$consumed clotting factors! platelets for thrombocytopenia! cryo for hypofibrinoginemia#. In austere conditions however! such blood products are often in limited supply or altogether unavailable. In such settings! fresh whole blood may be the only source of blood components available for the management of hemorrhagic shoc% in casualties. Current experience in &I"$&'" has suggested a significant survival benefit of both platelets and ()( ""P)R C ratios in massively transfused casualties (* (+ units R Cs in ,- hours#. .assively transfused casualties have a high mortality of ,,/ at -0 hours and --/ at 1+ days and have the highest potential to benefit from appropriate transfusion strategies. "resh whole blood provides a ()( ""P)R C ratio and additionally provides an important source of platelets (which are fre2uently unavailable because apheresis platelets only have a 3 day shelf4life#. "W is neither intended nor indicated for routine use. ecause "W has both R Cs and plasma! it must be 5 & type4specific (there is no universal donor of "W #. 6here are ris%s associated with the use of "W to include increased ris% of transmitted blood4borne diseases (such as hepatitis C or syphilis#! a period of decreased exercise tolerance in donors (fre2uently other members of the unit of the casualty#! and increased ris% of clerical errors (5 &4typing# due to the fre2uently chaotic resuscitation during which "W is re2uested. 5dditionally! field conditions are inherently unsanitary and are presumed to increase the ris% of bacterial contamination of the blood Rapid pre4 transfusion viral testing %its are available in theatre to mitigate the ris% of viral disease transmission! but have limited sensitivity$specificity. 6herefore! it is 7&6 appropriate! as a matter of convenience! as an alternative to more stringently controlled blood products.

Guideline &nly47ot a 8ubstitute for Clinical 9udgment

Clinical Practice Guideline

It is to be used only when other blood products are unable to be delivered at an acceptable rate to sustain the resuscitation of an actively bleeding patient or when specific components are not available (R C:s! platelets! cryoprecipitate! ""P#

2. Recommendations: 6he use of "W should be reserved for trauma victims who are anticipated to re2uire massive transfusion ((+ or more units R C:s in ,- hours# or for patients with clinically significant coagulopathy (bleeding with thrombocytopenia or I7R;(.3# when optimal component therapy (particularly apheresis platelets and fresh fro<en plasma# are unavailable. a. =evel III facilities (where full component therapy including apheresis platelets is available#) the ris%)benefit ratio may not >ustify the routine use of "W over ban%ed blood products! even in severe trauma. ?owever! when platelet and ""P inventories are depleted! or in contingencies such as .58C5= situations when the blood inventory may be exhausted! the use of "W remains a life4saving option. b. =evel III and =evel II @ or =evel II 8urgical facilities (where apheresis platelets are not available#) Current data suggest that "W improves survival compared to R Cs and ""P alone in severely in>ured patients. It is a clinical >udgment of the physician whether the benefits of using "W outweigh the ris%s given the other components available. In this setting! "W may best be viewed as an alternative source of platelets. c. =evel II and below) the use of "W remains a life4saving tool in the management of severe trauma! providing proper training and planning has occurred! and proper e2uipment is available. (Refer to AB below.# 3. uidelines: a. 6he decision to use "W is a medical decision that must be made by a physician who has full %nowledge of the clinical situation! as well as the availability of compatible blood components. b. In general! the use of "W should be limited to casualties anticipated to re2uire a massive transfusion when the physician determines that optimal component therapy 44 including ""P! apheresis platelets! and cryoprecipitate 44 is unavailable or in limited supply. c. 6he decision to initiate a "W drive should be made in consultation with the appropriate .6" .edical 5uthority (8G?! CCC8! 6rauma Cirector! etc# and =aboratory$ lood an% &IC to both determine the availability of compatible blood components! as well as to coordinate the fresh whole blood drive. d. FWB must !e "atient grou"#t$"e%s"ecific (&B' identical) to the "atient( other)ise a fatal hemol$tic reaction ma$ result. e. ecause of the inherent ris%s of "W ! the ordering physician should sign an 'mergency Release Consent "orm ac%nowledging that the "W has not been

Guideline &nly47ot a 8ubstitute for Clinical 9udgment

Clinical Practice Guideline

tested for viral mar%ers and therefore does not meet "C5 standards. 6he decision to use untested whole blood is a medical decision that must be made with a full %nowledge of the facts of the case and should be ade2uately documented in the patient medical record.

*. +recautions: Crawing fresh whole blood in the field may be dangerous for several reasons) a. ,here is no uni-ersall$ com"ati!le FWB t$"e. 6ransfusions of fresh whole blood must be 5 & matched (and Rh matched for female casualties of child4 bearing potential#. 8ervice members: blood types are not always %nown with certainty. 6he blood type on Ddog tagsE is occasionally inaccurate and should not be relied upon to determine blood type for either donors or recipients. b. ecause it is not sub>ect to the same strict 2uality controls and infectious disease testing as ban%ed blood! "W does not meet F8 "C5 standards and has an increased ris% of blood4borne disease transmission (e.g.! hepatitis C! ?IG! syphilis#. c. In emergency situations! particularly when more than one blood type is being collected! there is an increased ris% of a clerical error leading to a life4threatening transfusion reaction. d. "ield conditions are inherently unsanitary and increase the ris% of bacterial contamination of the blood. e. Fse of non4standard transfusion e2uipment may lead to coagulation during the transfusion. .. +lanning: a. 8ince the need for "W cannot be predicted! a robust contingency operational plan should be developed by the .6" 8taff to include the =aboratory$ lood an% and surgical and anesthesia providers. 6he plan should be reviewed and rehearsed regularly. b. If practical! establish a pre4screened donor pool using the lood Conation Huestionnaire (CC "orm 3I, or .8 Word version#! preferably composed of active duty! active reserve! active 7ational Guard! and other CoC beneficiaries (Coalition and "oreign 7ationals shall not be used#. Recent laboratory confirmation of blood group$type and non4reactive status for transfusion4 transmissible disease tests is ideal! but does not obviate the need for confirmatory testing. Jeep the donor file current. c. In an emergency, rapidly establish 5 &$Rh of donors and patients on4site by using appropriate reagents$tests! to include test tubes and$or diagnostic screening cards! in con>unction with previous blood donor history records! if available. d. 'very effort should be made to adhere to the same screening! drawing! labeling and issuing standards re2uired for F8 "C5 approved blood products.

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Clinical Practice Guideline

e. 6he physical donation site should be organi<ed in such a way as to maintain the integrity of the screening and donation process and to minimi<e the possibility of clerical errors. 6his is especially important in emergency situations. f. It is highly recommended! where feasible! to perform on4site testing of potential blood donors using rapid screening immunoassays for infectious diseases 44 specifically ?IG! ? G! ?CG 44 before "W is transfused. Regardless whether the local testing is performed pre4 or post4transfusion! these tests are not licensed for donor testing and samples must be sent to a reference lab for "C54approved testing. 5 mechanism must be in place to ensure that both the recipient and donor can be notified should the results be positive. g. A contingency plan should be developed for collecting! storing! and transfusing "W in .58C5= situations. 8imilarly! when it is deemed that the current blood inventory will be exhausted prior to re4supply! consideration should be given to initiating a "W drive! even when ban%ed components are still available (such as when multiple type4& trauma patients are exhausting the & R C inventory# 6. Procedure a. When planning or when arriving at a remote location try to set up a walking blood bank with pre-screened donors using the Blood Donation uestionnaire, pre!erably active duty, active reserve, active national guard, and DoD bene!iciaries. "ecent laboratory con!irmation o! blood group#type and non-reactive trans!usion transmissible disease tests represent the best screening candidate. $eep the donor !ile current. b. %n an emergency, establish AB&#"h o! donors via local testing or previous donor history. %t is highly recommended, where !easible, that all '()s per!orm rapid, on-site viral marker screening tests o! potential blood donors using screening immunoassays !or in!ectious diseases, speci!ically *%+, *BsAg, *,+, be!ore !resh whole blood is trans!used. %! not clinically !easible to test be!ore the blood is trans!used, rapid, on-site viral marker testing should nevertheless, be per!ormed as soon as !easible on-site and results recorded appropriately. -.-s !or rapid viral marker screening assays are listed in Appendix B. c. %n addition, all '()s will have retrospective /a!ter-the-!act0 testing !or in!ectious disease markers per!ormed on all donor specimens, at an )DA-approved, DoD-sanctioned laboratory in accordance with )DA#AABB standards o! medical care1 collect 2 3D(A tubes /44( or 4urple (op0 and 5 red top tube. d. ,hoose prior blood donors in pre!erence to non-donors because they have been tested !or in!ectious diseases in the past. "ely on dog tags !or AB&#"h in a deployed setting, only as a last resort, in the absence o! other options, to prevent imminent death.

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Clinical Practice Guideline

e. Choose a blood donor whose !resh warm whole blood is AB&identical with intended recipient /patient0. !. ,lean the donor6s arm with povidone iodine, or appropriate alternate antiseptic agent, !or at least one minute or per kit recommendations. g. Draw the blood !rom an arm vein into an in-date, intact commercial blood bag. (he bag is usually o! 788 ml capacity and contains 79 ml o! ,4D or ,4DA-5 anticoagulant. Draw about 2:8 ml, a pint, so that the bag is almost !ull /over!illing may cause clotting and recommend scale be used !or accuracy, when available, to measure 2:8 ;#- :8 ml0. Draw tubes !or typing, cross-matching, and trans!usion transmitted disease testing. .end donor pilot tubes to a supporting theater Blood .upport Detachment !or transport via established channels to an )DAapproved DoD re!erence testing laboratory /<ackland A)B or )ort *ood0. <abel the blood collection bag clearly with AB&#"h and donor-uni=ue identi!ying in!ormation, i.e., %.B(-5>? alphanumeric labels.. h. A!ter twenty-!our />20 hours, destroy all warm-stored /room temperature0 !resh whole blood units. %! the whole blood is re!rigerated within ? hours, it may be stored !or up to : days, though the blood product will only have "B,s and plasma as platelets =uickly become non-viable when stored at 2o,. Blood stored !or more than >2 hours at room temperature has a signi!icant risk o! bacterial growth. i. When issuing the blood to an operating team, ensure that the anesthetist#anesthesiologist and surgeon understand that this is an emergency @drawn unit and tell them the history o! the unit. A. $eep a record o! donors and patients trans!used so they can be !ollowed-up and tested %AW &A.D#*A memo dated 2 Dec >8851 !orward trans!usion in!ormation to the appropriate Blood .upport Detachment#3Bpeditionary Blood (ransshipment ,enter !or !ollow-up with the ,3-(,&' Coint Blood 4rogram &!!ice /CB4&0 and Coint (heater (rauma "egistry /C((.0.. k. $eep an '() record o! number o! units trans!used, who the donors were, and outcome. l. Remember, the decision to transfuse fresh warm whole blood is a medical decision that must be made with a full knowledge of the facts of the case and should be adequately documented in the patient medical record. NO !" All )WB collection documentation /DD )orm :D>0, testing and trans!usion records are the property o! ,3-(,&' Coint Blood 4rogram.

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Clinical Practice Guideline

,entraliEed storage o! records allows !or the long-term retrieval and compliance with blood program regulations. F4DA(3DG 'ay >88? H3&"H3 4. ,&.(A-I& ,ol, F.A), ',, .). C((. Director References" ,3-(,&' )"AH& 8J-5>>>G Coint (heater Blood 4rogram FpdateG 2 'ay >88D '-,-% )"AH& 8?? K>: CA- 8? D(FL, (o '-,-% &4&"D 8?-85, 4aragraph >.D. ()?> )"AH& -----M 3mergency War .urgery, (hird F. "evision, ,hap DG .hock and "esuscitation, >882 (heater '()-speci!ic .tandard &perating 4rocedures /.&4s0 6echnical .anual! 55 ! ethesda .aryland! (3th 'dition! ,++3 . 8tandards for lood an%s K 6ransfusion 8ervices! 55 ! ,3th 'd! "ebruary ,++0

Appendix A 1. Background: In every conflict since WWI! the military has used whole blood in resuscitation of combat casualties. In fact! =6G =eonard ?eaton once stated that! D& any single medical program can be credited with the sa%ing o countless li%ed in 'orld 'ar && and the (orean 'ar, it was the prompt and liberal use o whole blood.E ?owever! following the development of fractionation techni2ues in the (L3+:s! the use of whole blood was largely abandoned in civilian trauma centers in favor of blood component therapy. ut! because the military often practices in austere and remote environments where platelets and ""P are unavailable and even red blood cell supplies are limited! fresh whole blood ("W # is fre2uently the only option for transfusion. 5s more sophisticated medical assets are pushed closer to the front! military physicians find that they have more choices. While "W is clearly effective! it is un%nown whether it is more effective than component therapy which is now more widely available. 8imilarly! while the ris%s of ban%ed blood are well4%nown! the ris%s of untested "W collected from deployed donors in a field environment are as yet uncharacteri<ed. 6o ma%e an informed decision regarding the use of "W ! physicians must understand the ris%s and benefits of "W compared to those of available component therapy.

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Clinical Practice Guideline

2. /-idenced%!ased Re-ie): Prospective "W donors in4theater are generally young! healthy active duty service4members who receive comprehensive preventive health care including vaccination for hepatitis and regular screening for ?IG. Cespite these precautions! some transfusion4transmitted infections do not have effective vaccines and are not screened prior to deploymentM namely! hepatitis C virus (?CG#! human 64cell leu%emia virus (?6=G#! and syphilis. "urthermore! other transfusion4transmitted infections such as malaria and =eishmaniasis are endemic in many areas where military personnel are deployed. 5lthough presumably low! the prevalence of these infections among prospective donors in theater is un%nown. 5nd while standard donor screening is performed! potential donors may feel pressured to compromise the screening process! either by their command or out of a desire to help their fellow soldiers. In any case! deployed soldiers would not be allowed to donate blood in the Fnited 8tates under "C5 regulations. 6he "C5 has rigorous standards for testing of blood products for transfusion4transmitted infections. While post4transfusion testing is performed on all whole blood donations! pre4 transfusion screening of products is limited. Rapid viral tests for ?IG ($,! ? G! and ? C are available at Ibn 8ina ?ospital in aghdad and at the 11, '.CGM and some level II facilities have access to rapid ?IG($, tests. C'76C&. guidance on whole blood transfusion highly recommends that such testing be performed prior to transfusion! when practical. 5t the present time these %its are available to all facilities where "W may be collected and transfused. 6hey >ust have to be ordered. 5s a result! of approximately 3!1++ emergency transfusions! there have been at least , documented cases of ?CG and (( documented cases of ? G contamination in "W use in &'"$&I". (58 P# Whatever the ris% of transmitting an infectious disease by transfusing "W collected in4 theater (even if untested#! it is clearly much smaller than the ris% of death from hemorrhagic shoc% (N(/ compared to 1+43+/#. ut! with the increased availability of other ban%ed blood components! military physicians now may have other options besides >ust "W and R Cs. While "W may be the only choice at a level II facility where platelets and$or ""P are not available! the blood ban% capabilities at level III C8?s approach those of a stateside trauma center. In that setting! the consensus opinion among civilian blood ban%ers appears to be that the Droutine use o pathogen)untested blood products merely to obtain some potential relati%ely small unctional bene it rom resh blood Ois not >ustifiedPE. (California lood an%ers 8ociety "orum# 6he actual process of collecting and transfusing "W in the combat environment presents several logistical problems. While blood donor centers in the F8 are highly regulated with respect to donor screening procedures! 2uality control and testing protocols! staff training re2uirements! and even the physical facility re2uirements! the collection of whole blood in the field is often performed under less than optimal conditions. ecause they are generally not staffed for emergency blood collection! the laboratory often must suspend other activities (e.g.! routine labs and blood testing# in order to collect and process the "W . "inally! because "W is generally re2uired

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Clinical Practice Guideline

emergently! the donor center staff may be more prone to technical and clerical errors 44 particularly when more than one blood type is being collected. &n the other hand! several authors have shown that! by reducing the total number of blood products transfused! the use of whole blood actually reduces the chance of clerical errors in the operating room. Importantly! in cases re2uiring rapid and massive transfusion where ease of administration is important! "W clearly has a clear advantage over component therapy. (=aine! et al.! 6ransfusion! ,++1! -1)1,,41,I# Repine! et al.! cite numerous examples of emergency whole blood drives! pointing out that Donce donor populations are de ined and characteri*ed in a massi%e trans usion or mass)casualty situation, the logistical balance tilts toward the utili*ation o whole blood.E (Repine! et al.! 9 6rauma! ,++B! B+(B8#)83L4BL# 6he use of "W clearly reduces the logistical burden at the patient bedside! providing for simpler and more rapid infusion of blood. It is well %nown that ban%ed red blood cells develop a so4called Dstorage lesionE (decreased nitric oxide! decreased p?! decreased ,!14CPG! and decreased 56P# which reduces oxygen4carrying capacity. &ther drawbac%s of ban%ed blood include hypocalcemia from citrate anticoagulant! hyper%alemia from increases in extracellular potassium during storage! and hypothermia. 8ome researchers have lin%ed such changes to adverse clinical outcomes (?o! et al.! Crit Care .ed! ,++1! 1(((,8#)8B0I4BLI#.# 6his needs to be %ept in mind when dealing with military trauma patients with multiple massive in>uries and severely compromised physiology. Fse of fresher blood (N(- days of storage# and blood warmers should mitigate some of these problems. It has also been suggested that there are increased levels of inflammatory mediators in ban%ed blood which may lead to adverse outcomes (8illiman! et al.! 9 =ab Clin .ed! (LL-! (,-(3#)B0-4L-# 6hese findings were not confirmed in a ,++- article (.ou 88! et al! 7 'ngl 9 .ed ,++-! 13(((B#)(B134(B--#! however! perhaps because of the use of leu%ocyte4reduced products. Indeed! many of the drawbac%s of ban%ed blood cited in the older literature have been addressed by measures such as the development of improved additive solutions! the routine use of leu%ocyte4reduction (particularly at donation#! and the advent of apheresis platelets. While the physiology and ris%s of blood component therapy have been extensively studied! the use of "W has not. It has been suggested that! because "W contains fresher! more functional components which are present in more physiologic concentrations! it should be more effective than ban%ed blood. 6his theoretical advantage has never been proven clinically! however. DThe notion has long been accepted that the use o resh whole blood+guarantees the pro%ision o all cellular and noncellular blood components. ,oreo%er, it seems intuiti%e that a manipulated or reconstituted product should be less desirable than a natural, unmanipulated product. -uch belie s ha%e been supported o%er time by potentially biased anecdotal clinical obser%ations and %arious theoretical e.planations, which ha%e remained untested.E (.ou! et al.! 7. 'ngl. 9. .ed.! ,++-! 13(((B#)(B13#

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Clinical Practice Guideline

6he immunomodulatory effects of "W also remain un%nown. "resh whole blood contains fully activated donor leu%ocytes and may even induce a transient graft4versus4 host response. In their 7'9. article! .ou! et al.! speculated that the less favorable outcomes in the group receiving "W may be related to the Din lammatory mediatorsE not evaluated in their study but which Dcannot be dismissedE. When reading the literature in this area! it is important to note the distinctions between resh whole blood and whole blood which may be only ,-41B hours old! but which has been refrigerated. Platelet function is rapidly and irreversibly diminished following refrigeration of storing whole blood even for short periods of time ( aldini! lood! (LB+! (B (B#) (BBL4L,#. 8imilarly! there are significant physiologic and clinical differences between the pooled platelets used in older studies and apheresis platelets which are commonly used today (and are available in4theater#. 5pheresis platelets are more active! contain fewer white cells! and expose recipients to only a single donor:s blood. 6o date! there have been no prospective randomi<ed clinical trials comparing "W to component therapy in the trauma setting. Retrospective data from the Combat 8upport ?ospital in aghdad during &I" in -1- massively transfused patients! however! has shown that resuscitation with platelets (either in the form of apheresis platelets or "W # shows is associated with improved survival over R Cs! ""P! and cryo alone.(see "igure (# even on multivariate analysis. 6here was no difference in survival however when comparing casualties resuscitated with apheresis platelets as compared to "W . ("igure ,#.
P<0.001 p=0.04

Log Rank p=0.003

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Clinical Practice Guideline

p=0.72

p=0.87

Log Rank p=0.96

'rber! et al.! conducted a retrospective study of massive blood loss in trauma and demonstrated a reduction in total blood usage by using "W compared to routine component therapy. Interestingly! a reduction was only seen in the patients that survived. ('rber! et al.! .ed 9 5ust.!
(LLB! (B3((#)((41# Reeves4Giet! et al.! showed a similar reduction in total blood usage in thoracoabdominal aorta reconstruction between patients receiving whole blood and those who received pac%ed red cells. (Reeves4Giet! et al.! 7urse 5nesth.! (LL( ,(-#)(0-4I# Clearly!

"W is effective in resuscitation following massive blood lossM and according to these studies! it may reduce total blood product usage (and all the attendant ris%s#. "W has also been compared to ban%ed blood in a number of other clinical settings! among them) pediatric and adult cardiac surgery! transplant surgery! and others. In their prospective! randomi<ed! double4blind study in 7'9.! .ou! et al! demonstrated that the use of "W for cardiopulmonary4bypass circuit priming in neonates and infants does not confer a significant clinical advantage over reconstituted blood with respect to survival or length of ICF stay. (.ou! et al.! 7. 'ngl. 9. .ed.! ,++-! 13(((B#) (B13# &n the contrary! the use of "W was associated with a prolonged stay in the intensive care unit! increased perioperative fluid overload! and an increased duration of mechanical ventilation. .anno! et al.! performed a similar study which yielded mixed results. While there was a benefit to the "W group aged N, years! he found no significant difference in ,-4hour blood loss among children ; , years following open4heart surgery with CP who received either "W or reconstituted blood. (.anno! et al.! lood! (LL(! II) L1+# =oo%ing at the adult population! .ohr! et al.! compared the effectiveness of "W with that of platelet transfusions in patients having C P surgery and reported no statistical difference in postoperative blood loss after a transfusion of ( unit of "W compared with transfusion of (+ units of platelets. (.ohr! et al.! 9 Cardiovasc 8urg.! (L00! LB)31+#

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Clinical Practice Guideline

6hese more recent observations are also supported by Counts! et al.! who pointed out that bleeding following massive transfusion is primarily due to dilutional thrombocytopenia rather than coagulation factor deficiencies. (Counts! et al 5nn 8urg! (LIL! (L+)L(4LL# In fact! this finding has been consistently confirmed. In a study of blood use in orthotopic liver transplantation! =aine! et al.! showed here was no statistically significant difference in coagulation profiles between groups receiving "W versus R C and ""P. (=aine! et al.! 6ransfusion! ,++1! -1(1#)1,,4I#. 8imilarly! in his lood paper .anno! et al.! concluded that the difference in blood usage in his study between "W and reconstituted blood was not explained by postoperative coagulation tests. Interestingly! both .ohr and .anno went even further and concluded that any hemostatic benefit from "W is attributable to platelets. 6his finding was also suggested by =avee! et al.! who used electron microscopy to compare platelet aggregates from patients who received "W with those receiving pooled platelets. (=avee! et al.! 9 6horac Cardiovasc 8urg! (L0L! LI),+-4,(,# 6hese results suggest that "W can perhaps best be viewed as an alternative source of platelets when none are available.

&""endi0 B

Expendable Supplies
Item Manufacturer Vendor order number

Blood recipient set indirect !" #$t%pe &'& 6(1( 01 128 1407 'topcock )* t+erap% 3 ,a% ,it+ l-er &'& 6(1( 00 864 8864 Blood .ollection 'et &'& 6(1($01$480$2307 2"2 non$sterile ga-/e 0endall 3(83009022 2"2 sterile ga-/e 0endall 6(10014640826 41 2i3iclens Regent 4edical 5002340(7(04 )odine prep s,a3 Ba"ter 6(10011139208 .+-" 0endall 3(83001093 .o3an 34 4(0901(86( .old Packs 'o+gen 67-ropean8 6(300813(0791 !ape 19 34 4(0901(381 :lco+ol Prep P;) 472(.69900 Late" !o-rni<-et .ardinal 2ealt+ 2002P.6002 'tandard t-3e +older !er-=o P$1316R 21$ga-ge &eedles B; 723367210 :==onia )n+alants >a=es :le"ander .o. 6(0(00106087( 2 m< 3D(A BD D>997D?75 Dm< Hlass "ed (op BD 77988558?5222 <uer Adapters $endall ???5>>:>:D ,ollection Bags (erumo 7:5:8522D7?D5 (ube .ealing ,lips (erumo 7:5:85528:>7? ,overs !or temp probe Welch Allyn 7D?9:895585

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Clinical Practice Guideline

Reagents and Test Kits

Item Manufacturer Vendor order number

Bio"apid *BsAH Biokit /.pain0 7::88?599>>27 Bio"apid *,+ Biokit /.pain0 7::88?599>>2D "4" ,ontrol ,ard BD 7::88582J?7>? "4" $it BD 7::8852J9>>D9 &ra uick Advance "apid *%+ N Antibody (est $it&ra.ure (echnologies 7::885:>7D295 ,alibrator Arcent 7798852J87>85 ,ontrol .et Arcent 7::88527J7>88 A,( (ainer Arcent 7::88527D9789

Tools and Equipment

Item Manufacturer Vendor order number

.cissors -A 7:5:858782>?8 *emostatics Bausch O <omb 7:5:852:J9JD8 .tripper-.ealer-,utter (erumo 7:5:85528:>7D 'anual B4 ,u!! Halls 7:5:85>?J5J7D "ocker#'iBter .egger#(ube .ealer 3lectronic (hermometer Welch Allyn 7:5:8595979>2> BD 'acro-+ue "otator BD JJJJ>D?8:5 4ro4a= Blood pressure Act58 /*ematology analyEer0 ,oulter 77988527?J52> *ema,ool 'obile Blood .torage "e!rigerator # )reeEer 'odelG *',-'%<-5 -.-G 2558-85-:87-8?J: *elmer uick (haw 4lasma (hawing .ystem 'odel D*?G -.- 7728-85-:29-97>5 'odel D*? ,overG -.- 7728-85-:29-97:5 'odel D*2G -.- 7728-85-:58-9597 4lasma &verwrap bagsG -.- 7:5:-85-:55-97>2

Guideline &nly47ot a 8ubstitute for Clinical 9udgment