›Prone positioning for PaO2/FiO2 < 150 mmHg despite optimization
Antiviral therapy (investigational and compassionate use)
›Ribavirin
›No approved antiviral exists; ribavirin used on compassionate basis
›Associated with 36% mortality reduction in Malaysian outbreak (open-label, historical controls)
›No statistically significant benefit confirmed in 2018 Kerala outbreak
›Dosing: 30 mg/kg IV loading dose, then 16 mg/kg IV every 6 hours for 4 days, then 8 mg/kg IV every 8 hours for 6 days
›Alternatively: 2 g oral loading dose, then 1 g every 6 hours for 4 days, then 0.5 g every 8 hours for 6 days
›Adverse effects: haemolytic anaemia, teratogenicity; contraindicated in pregnancy
›Remdesivir
›Strongest preclinical evidence: protective in African green monkey NHP challenge model
›Protection when initiated within 24 hours of exposure
›NHP protocol: 12-day IV course
›No human efficacy data available
›May be considered in consultation with ID and public health if available
›Dosing extrapolated from COVID-19 protocols: 200 mg IV day 1, then 100 mg IV daily
›m102.4 monoclonal antibody
›Phase 1 safety data established in humans
›Targets henipavirus G glycoprotein
›Compassionate use protocol developed for future outbreaks
›Dosing: 20 mg/kg IV as single dose (or two doses 48 hours apart for established disease)
›Access via WHO, CDC, or national health authority emergency protocols
›Favipiravir
›Fully protective in hamster model
›No human data available
›Consider in context of outbreak and investigational framework
›Access pathway
›Contact WHO, CDC, or national health authority for investigational therapeutic access
›Document compassionate use consent and off-label rationale
Empiric and supportive pharmacotherapy
›Empiric acyclovir pending HSV exclusion
›Acyclovir 10 mg/kg IV every 8 hours
›Continue until CSF HSV PCR returns negative
›Dose adjustment required for renal impairment
›Seizure management
›First-line: lorazepam 0.1 mg/kg IV (max 4 mg per dose) for active seizure
›Second-line: levetiracetam 60 mg/kg IV loading dose (max 4500 mg)
›Alternative loading: valproate 40 mg/kg IV over 10 minutes
›Maintenance antiepileptic chosen based on clinical profile and drug interactions
›Vasopressor therapy for shock
›Norepinephrine 0.01-3 mcg/kg/min titrated to MAP >= 65 mmHg
›Vasopressin 0.03 units/min as adjunct for catecholamine-sparing
›Dobutamine for cardiogenic component: 2-20 mcg/kg/min
›ICP management
›Head-of-bed elevation to 30-45 degrees
›Mannitol 0.25-1 g/kg IV if herniation signs or ICP > 20 mmHg
›Hypertonic saline 3%: 2-5 ml/kg IV as alternative to mannitol
›ICP monitor insertion if GCS <= 8 and CT showing cerebral edema
General ICU supportive care
›Nutritional support
›Enteral nutrition via nasogastric tube once haemodynamically stable
›Target 25-30 kcal/kg/day
›Protein 1.2-2 g/kg/day
›DVT prophylaxis
›Enoxaparin 40 mg SC daily when no bleeding contraindication
›Mechanical prophylaxis (pneumatic compression devices) if anticoagulation contraindicated
›Stress ulcer prophylaxis
›Pantoprazole 40 mg IV daily for ventilated patients
›Glycaemic control
›Target blood glucose 7.8-10 mmol/l in critically ill
›Insulin infusion if persistently > 10 mmol/l
›Renal replacement therapy
›Continuous venovenous haemofiltration (CVVH) for acute kidney injury with fluid overload or refractory acidosis