Parenteral Therapy For Severe Malaria - Form A

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PARENTERAL THERAPY FOR SEVERE MALARIA - FORM A
To be completed by the Attending Physician
CMN ID:
1. Date of request
: ____/____/____
Test used
: RDT Thick smear
(D/M/Y)
(check all that apply)
Thin smear Other
:
(specify)
2. Drug requested
:
(check all that apply)
 Artesunate*
 Quinine
Malaria species
:
(check all that apply)
*For artesunate request, monitor CBC weekly for four weeks. Low
P. falciparum
P. vivax
P. malariae
risk for delayed hemolysis; if this occurs, the CMN must be notified.
P. ovale
P. knowlesi
Unknown
Percent parasitemia
:
%
(initial)
3. REQUESTING/ATTENDING PHYSICIAN
Percent parasitemia
:
%
(at start of IV therapy)
Name:
Hospital/site:
9. Has the patient had other medical treatment for this episode of
City:
Province:
malaria?
Yes No Unknown
Tel#:
Fax#:
If yes, specify what drug(s):
Email:
Who prescribed the drug?
4. PATIENT DEMOGRAPHICS
MD in Canada
MD in country of acquisition
Initials
: ____/____/____
(first/middle/last)
Self prescribed
:
Other
(specify)
Date of birth
:____/____/____
(D/M/Y)
10. Indication for use of IV antimalarial therapy
:
(check all that apply)
Sex: Male
Female, Pregnant: Yes
No
 Continued vomiting or unable to tolerate oral
Birth Country:
therapy
(Note: if this is the only indication for IV therapy,
If <18 years, country of parental origin:
then QUININE preferred)
Canadian Resident?: Yes
No
 Hyperparasitemia
(>2% in non-immune, >5% in semi-
Visitor?: Yes
No
immune)
 Impaired consciousness or coma
5. PATIENT TRAVEL INFORMATION
 Prostration
(unable to walk or sit up without assistance)
Presumed country(ies) of acquisition:
 Multiple convulsions
1)
2)
3)
(>2 in 24hrs)
 Respiratory distress
Date departed Canada
: ____/____/____
(acidotic breathing)
(D/M/Y)
 Respiratory failure / Pulmonary edema / ARDS
Date returned in Canada
: ____/____/____
(D/M/Y)
 Circulatory collapse / shock
(SBP<80mmHg in adults and
Reasons for travel (check all that apply):
<50mmHg in children)
Visiting friends/relatives Volunteer/missionary
 Acute kidney injury / renal failure
(Cr >265µmol/L or
Business
Education
Vacation
>upper limit for age for children)
Medical tourism
Immigration
Military
 Jaundice
(Total bilirubin >45µmol/L)
Other, specify:
 Abnormal spontaneous bleeding/DIC
 Hypoglycemia
(<2.2mmol/L)
6. PREVENTION MEASURES
 Metabolic Acidosis / Acidemia
(pH<7.25, HCO3<15mmol/L)
Pre-travel advice sought: Yes No
 Severe anemia
(Hb <70g/L in adults and <50g/L in children)
If yes, with whom?:
 Hemoglobinuria
(macroscopic)
GP/family physician Travel medicine clinic
 Hyperlactataemia
(lactate >5mmol/l)
Other:
 Other
:
(specify)
Insect precautions?: Yes No Unknown
11. The following refer to time taken to begin IV therapy and is
Was chemoprophylaxis...
used to establish where/why delays occur....
Suggested?:
Yes No Unknown
a) Hours to contact individual responsible for dispensing IV
Prescribed?:
Yes No Unknown
malaria therapy through the Canadian Malaria Network
Used?:
Yes No Unknown
:
(#hours)
b) Hours from request until drug received by pharmacy
If used, chemoprophylaxis type:
:
(#hours)
 Chloroquine
Doxycycline Malarone
c) Hours from time received in pharmacy until drug
 Mefloquine
:
Other
(specify)
administered
:
(#hours)
Adherence: Did they take the drug as prescribed
d) Comments/perceived reasons for delay(s), if any:
?
(before, during, after travel, missed <2 doses)
Yes No
Unknown
12. Other Comments:
7. PATIENT ILLNESS
Date became ill
: ____/____/____
(D/M/Y)
Date of 1st physician visit
: ____/____/____
(D/M/Y)
Completed by:
Was the patient admitted to hospital?: Yes No
Date: ____/____/____ Tel #:
If yes, date admitted
: ____/____/____
(D/M/Y)
Email:
8. DIAGNOSIS
Thank you very much for completing this form.
Diagnosis lab-confirmed: Yes No
Please complete Form B (follow-up)
Date
: ____/____/____
(D/M/Y)
at day 7 and send it in.
Form Version: November 2013
PLEASE COMPLETE AND RETURN TO THE CMN COORDINATING CENTRE WITHIN 24 HOURS OF
STARTING IV DRUG TREATMENT BY E-MAIL:
CanadianMalariaNetwork@toh.on.ca
OR BY FAX: 613-737-8164
Parenteral artesunate and quinine are provided by Health Canada’s Special Access Program through the Canada Malaria Network (CMN).

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