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Error File |
The Acts of Commission And Omission
Misdiagnosis |
Over-diagnosis
Obsession with malaria and forgetting the OTHER
causes of fever |
In
an endemic area, there may be a tendency to diagnose all cases of fever as malaria,
forgetting to even consider other causes. Whereas presumptive treatment with chloroquine
in cases of fever is well accepted, sometimes, doctors may go beyond that and indulge in
presumptive treatment with newer drugs, (reserved for multi drug resistance falciparum
malaria), even if the MP test is repeatedly negative. Most often such cases turn out to be
non-malarial fevers. Therefore, DO NOT FORGET THE OTHER CAUSES OF
FEVER. |
Under-diagnosis
Forgetting malaria |
1.
Malaria may not be considered as a possibility in places where it is not common-history of
travel to malarious area should be elicited.
2. It may not be considered in patients on chemoprophylaxis for malaria. Chemoprophylaxis
does not offer 100% protection and malaria should be therefore looked for in these
patients.
3. Malaria can always co-exist with other infections in an endemic area. Therefore, it
should be considered even in patients with other obvious infections causing fever. |
Misreport |
False positive |
Artifacts
may be read as malarial parasites on peripheral smear as well as QBC test. Dirty slides,
contaminated stains, inexperienced microscopist, recycled QBC tubes may be the causes. |
False negative |
Malarial
parasites may be missed and the test reported as negative. Inadequate smear, dirty stains,
contaminated/deteriorated stains, wrong buffer pH, inexperienced technician, incomplete
examination of the slide, storage of blood in anticoagulant before preparing the smear
etc. may contribute to this problem. |
Mis-judgement
of severity |
Over-estimation |
Panic
reaction to P. falciparum malaria is common among patients and not uncommon among doctors,
resulting in over-reaction to the situation and over-treatment. Mild anemia, mild icterus,
headache etc. are common in falciparum malaria and need not necessarily imply severe
malaria. Such patients need not be treated with parenteral or second line antimalarial
drugs. See: Criteria for severe malaria. Also it
should not be forgotten that some of the manifestations could be due to fever, drugs etc.,
and not necessarily due to severe malaria. |
Under-estimation |
P.
falciparum malaria can cause dramatic complications and therefore one should be
always looking for them. Patients who are at increased
risk for development of complications should be ideally admitted for observation. Any
indication of complication should be properly managed. Neglecting the signs like high
fever, prostration, significant pallor and jaundice, dehydration etc. may prove costly. Hypoglycemia may be easily missed. |
Mismanagement |
Over-treatment |
(1.)
Use of parenteral antimalarials when not needed can cause
unnecessary hardship to patient. (2.) Using 2nd line
antimalarials when not indicated- this only adds to the cost of therapy and to the
adverse effects. It also depletes our stock of reserve antimalarial drugs and exposes them
to the risk of development of resistance. (3.) Using 2-3
antimalarial drugs concurrently (4.) Higher dose and longer
duration: Antimalarial drugs do not offer better efficacy at higher dose, this only
adds to the adverse effects. (5.) Failure to switch to oral therapy: Unnecessary continuation of parenteral therapy may
increase the adverse effects and also cost of therapy. (6.) Rapid
intravenous infusions of chloroquine and quinine may
be fatal. (7.) Over-hydration and fluid overload:
Enthusiastic administration of fluid and/or blood may precipitate acute pulmonary oedema.
(8.) Unnecessary endotracheal intubation in comatose patients
who can be managed with conservative measures. (9.) Use of
potentially dangerous ancillary therapies: Corticosteroids, anti-inflammatory
agents, dextran, heparin, adrenaline, prostacycline etc. should be avoided. |
Under-treatment |
(1.)
Delay in starting treatment: Delay in initiating treatment in
a case of severe malaria may prove costly. In such cases, if the suspicion of malaria is
high, treatment should be started even without waiting for the report or even if the
initial report is negative. Also non-availability of a particular dug should not delay the
initiation of therapy. (2.) Withholding antimalarial drug for
fear of toxicity etc. (3.) Inadequate dosage: Dose should
always be calculated as per the body weight of the patient. Inadequate dose may not be
effective. (4.) Miscalculation of the dose due to base-salt
confusion. (5.) Failure to identify the
need for parenteral therapy in severe malaria and to identify therapeutic
priorities in severe malaria (6.) Oral therapy in severe malaria (7.) Stopping antimalarial
therapy for minor side effects is unjustified. Always weigh the benefits and risks.
(8.) Failure to control convulsions (9.) Failure to recognize and treat severe anemia
(10.) Delay in starting mechanical ventilation in patients
with ARDS, metabolic acidosis etc. (11.) Delay in starting dialysis
in cases of renal failure (12.) Delay in considering obstetrical
intervention. |
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