Parenteral Therapy For Severe Malaria - Form B To Be Completed By The Attending Physician

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PARENTERAL THERAPY FOR SEVERE MALARIA - FORM B
To be completed by the Attending Physician
1.
Date (D/M/Y):______________
15. Malaria complications (check all that apply):
[ ] Impaired consciousness or coma
2.
Date IV drug requested (D/M/Y):_________________
[ ] Spontaneous bleeding/DIC
[ ] Severe anemia (Hb ≤50 g/L)
3.
Drug requested: [ ] Artesunate [ ] Quinine
[ ] Renal failure (Cr>265 µmol/L or >upper limit for
age for children
4.
Requesting/Attending physician:
[ ] Pulmonary edema/ARDS/resp failure
_____________________________________
[ ] Circulatory collapse/shock (SBP<80mmHg + cold
5.
Requesting site:________________________
extremities)
Province of requesting site:_______________
[ ] Seizures
[ ] Multiorgan failure
6.
Patient initials (first/middle/last):_________________
[ ] Other:____________________________________
Date of birth (D/M/Y):________ Sex: [ ] Male [ ] Female
16. Were there any complications or adverse events related
7.
Date diagnosed (D/M/Y):_____________
to IV antimalarial drug?
[ ] Yes [ ] No
8.
Date given 1
dose of IV drug (D/M/Y):____________
st
If yes, please specify:_____________________________
9.
Patient outcome as of today’s date (check all that apply):
17. Is this program to provide IV malaria therapy helpful
[ ] Alive [ ] Still hospitalized
to you? [ ] Yes [ ] No
[ ] Discharged
Date (D/M/Y):_____________
[ ] Deceased
Date (D/M/Y):_____________
18. Did you consult with a physician through the
Canadian Malaria Network?
10. Hospitalization
[ ] Yes [ ] No
Total days hospitalized:________
Days in ICU:________
19. If yes, was this a beneficial interaction?
[ ] Yes [ ] No
11. Drug utilization
Number of doses of IV drug administered:____________
20. Comments:_______________________________________
Number of vials used:___________
____________________________________________
12. Step-down therapy or second antimalarial (please specify
and give number of DAYS of therapy):
______________________________________________
[ ] Clindamycin
(# days):__________
21. Suggestions to improve the program:_______________
[ ] Doxycycline
(# days):__________
[ ] Malarone
(# days):__________
______________________________________________
[ ] Quinine oral
(# days):__________
[ ] Other (specify):______________ (# days):_________
______________________________________________
13. Number of days until negative smear achieved:_________
______________________________________________
14. Malaria complications (check all that apply):
[ ] Impaired consciousness or coma
Thank you for completing this form.
[ ] Spontaneous bleeding/DIC
Your cooperation is greatly appreciated.
PLEASE COMPLETE AND RETURN TO THE CMN COORDINATING CENTRE
BY E-MAIL: jlevine@ohri.ca OR BY FAX: 613-737-8164 WITHIN 48 HOURS OF IV DRUG
REQUEST.
Parenteral artesunate and quinine are provided by Health Canada’s Special Access Program through the Canada Malaria Network (CMN).

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