-Before treatment Time to parasitemia < 1% (hours): - 6 hrs after 1st dose Parasite clearance time (in hours): -12 hrs after 1st dose -24 hrs after 1st dose -48 hrs after 1st dose -72 hrs after 1st dose Specific supportive therapy Complications during antimalaria treatment: ☐ None ☐ None ☐ Mechanical ventilation ☐ Treatment failure (R-1 resistance) ☐ Haemodialysis ☐ Bacterial superinfection/sepsis ☐ Exchange transfusion ☐ Circulatory collapse (Shock) ☐ Erythrocyte apheresis ☐ Respiratory failure ☐ Vasopressor therapy ☐ Pulmonary oedema ☐ Antibiotic therapy ☐ Acute renal failure ☐ Transfusion of RBC ☐ Coma or Convulsions ☐ Transfusion of clotting factors ☐ Metabolic acidosis (pH <7,25) ☐ Spontaneous bleeding or DIC ☐ Hypoglycaemia (<40mg/dl) Outcome: ☐ Clinical and parasitological cure ☐ Clinical improvement (with sequellae, e.g. renal impairment) (N° days till death: ) ☐ Death ….. Follow-up at day 7 Yes / No Outcome details: Follow-up at day 14 Yes / No – Follow-up at day 28 Yes / No Anaemia or hemolysis Yes / No ☐ Abnormal liver function test Yes / No ☐ Follow-up: after 1st dose Abnormal creatinine Yes / No ☐ Neurologic abnormalities Yes / No ☐ Other abnormalities on follow-up examination: Adverse drug reaction suspected? Yes / No Screening for adverse drug reactions (severe anemia and other) Day of Day of Adverse drug reaction onset cure Severity of maximum intensity Relation with drug (Drug name + adverse drug Day Day ≠ ≠ reaction) Mild, no Moderate, Severe, No Possible Probable specific specific disabling or medication treatment needed needed ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
-Before treatment Time to parasitemia < 1% (hours): - 6 hrs after 1st dose Parasite clearance time (in hours): -12 hrs after 1st dose -24 hrs after 1st dose -48 hrs after 1st dose -72 hrs after 1st dose Specific supportive therapy ☐ None ☐ Mechanical ventilation ☐ Haemodialysis ☐ Exchange transfusion ☐ Erythrocyte apheresis ☐ Vasopressor therapy ☐ Antibiotic therapy ☐ Transfusion of RBC ☐ Transfusion of clotting factors Complications during antimalaria treatment: ☐ None ☐ Treatment failure (R-1 resistance) ☐ Bacterial superinfection/sepsis ☐ Circulatory collapse (Shock) ☐ Respiratory failure ☐ Pulmonary oedema ☐ Acute renal failure ☐ Coma or Convulsions ☐ Metabolic acidosis (pH <7,25) ☐ Spontaneous bleeding or DIC ☐ Hypoglycaemia (<40mg/dl) Outcome: ☐ Clinical and parasitological cure ☐ Clinical improvement (with sequellae, e.g. renal impairment) ☐ Death (N° days till death: ….. ) Outcome – details: Follow-up at day 7 Follow-up at day 14 Follow-up at day 28 Yes / No Yes / No Yes / No Follow-up: after 1st dose ☐ Anaemia or hemolysis ☐ Abnormal liver function test ☐ Abnormal creatinine ☐ Neurologic abnormalities Yes / No Yes / No Yes / No Yes / No Other abnormalities on follow-up examination: Screening for adverse drug reactions (severe anemia and other) Adverse drug reaction suspected? Yes / No Adverse drug reaction (Drug name + adverse drug reaction) Day of onset Day ≠ Day of cure Day ≠ Severity of maximum intensity Relation with drug Mild, no specific medication needed Moderate, specific treatment needed Severe, disabling or No Possible Probable ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐
IV%20artesunate%20SEVERE%20MALARIA%20Reporting%20Form%20VS%2012-2017.docx