Like everyone, I think each situation/conditions/Dx mandate what action to take (this is difficult in these times of cross-trained staff and need for "one size fits all" policies. The important issues to consider are the 1) volume of the transfusion, 2) the rate in which products are transfused, 3) when (or if) the RBC products were irriadiated, 4) facilities ability to wash products, and 5) Dx/procedure (OHS, ECMO, hyperkalemia, heart issues?). Also keep in mind the accumulative effect of several small volume (60ml) transfusions. Donor exposure has become much less of an issue with improved ID testing (and relatively stable O neg donor popultation) according to our blood suppliers, so we try to keep things in perspective. We use fresh (<5d, if fresh not available wash an older unit), LR, irradiated upon issue, HbS neg units for large volume transfusions (>60ml). Our pediatric cardiac team is much less interested in donor exposure than K+. Our PICU and NICU are more interested in limiting donor exposure. We are lucky that we can irradiate and wash units in-house and we are one block from our blood supplier, but it's still a complex process and requires a moderate level of decision-making not possible with all staff - all the more complicated by our litigeous society and healthcare industry run out of (cost) control. Good luck everyone! Diane