Parenteral Therapy for Severe Malaria - Form B

To be completed by the Attending Physician

1. Date (D/M/Y):
2. Date IV drug requested (D/M/Y):
3. Drug requested: Artesunate   Quinine
4. Requesting/Attending physician:
5. Requesting site:
   Province of requesting site:
6. Patient initials (first/middle/last):
   Date of birth (D/M/Y):                              Sex: Male   Female
7. Date diagnosed (D/M/Y):
8. Date given 1^st dose of IV drug (D/M/Y):
9. Patient outcome as of today’s date (check all that apply):
   Alive
   Discharged
   Deceased

   Still hospitalized
   Date (D/M/Y):
   Date (D/M/Y):
10. Hospitalization
    Total days hospitalized:
    Days in ICU:
11. Drug utilization
    Number of doses of IV drug administered:
    Number of vials used:
12. Step-down therapy or second antimalarial (please specify and give number of DAYS of therapy):
    Clindamycin
    Doxycycline
    Malarone
    Quinine oral
    Other (specify):

    (# days):
    (# days):
    (# days):
    (# days):
    (# days):
13. Number of days until negative smear achieved:
14. Malaria complications (check all that apply):
    Impaired consciousness or coma
    Spontaneous bleeding/DIC
    Severe anemia (Hb ≤50 g/L)
    Renal failure (Cr>265 µmol/L or >upper limit for age for children
    Pulmonary edema/ARDS/resp failure
    Circulatory collapse/shock (SBP<80mmHg + cold extremities)
    Seizures
    Multiorgan failure
    Other:
15. Were there any complications or adverse events related to IV antimalarial drug?
    Yes

    No

    If yes, please specify:
16. Is this program to provide IV malaria therapy helpful to you?
    Yes

    No
17. Did you consult with a physician through the Canadian Malaria Network?
    Yes

    No
18. If yes, was this a beneficial interaction?
    Yes

    No
19. Comments:
    
    
    
    
    
20. Suggestions to improve the program:
    
    
    
    
    

Thank you for completing this form.
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).