Nsaids

Division of National Malaria Programme – Komesha Malaria, Okoa Maisha
Ministry of Health
Module 2: Learning Unit 2
Management of Severe Malaria
Training of Malaria Case Management
Master trainers

National Malaria Control Programme – Komesha Malaria, Okoa Maisha
Learning Unit 2:
Management of Severe
Malaria

Learning objectives
By the end of the learning unit, the participants will be
able to:
1. Identify signs and symptoms of Severe malaria
2. Diagnose Severe malaria
3. Describe pre-referral management of severe malaria
4. Describe management of severe malaria

Signs and symptoms of Severe Malaria
Severe malaria is a life threatening condition defined as Peripheral parasitaemia in the
presence of the following clinical or laboratory features
• Prostration,
• altered consciousness,
• respiratory distress,
• multiple generalized convulsions,
• severe anaemia (Hb<5g/dl),
• hypoglycaemia (<2.2mmol/l),
• jaundice
• NB- features may occur singly or in combination,

What are the signs and symptoms of
severe malaria
(Brainstorm)
GROUP
BRAINSTORMING
What are the signs
& symptoms of
severe malaria?
14

Conjugate deviation of the eyes to the left or upwards
6

National Malaria Control Programme – Komesha Malaria, Okoa Maisha 7

11

12

13

Diagnosis of Severe malaria

Role of laboratory diagnosis in severe
malaria
• Parasitological confirmation is recommended
• Presumptive treatment should be started immediately
while waiting for parasitological confirmation
• Antimalarial treatment should not be withheld if
parasitological diagnosis is not possible or delayed
• Other investigations to determine severity and prognosis
should be undertaken where feasible
• (HB, Blood sugar, Urea and electrolyte)
• Positive slides do not rule out other causes of severe
disease

Clinical Manifestations of Severe Malaria
• Cerebral Malaria
• Severe Anaemia
• Hypoglycaemia

Assessment Tasks For Cerebral malaria (1)
i. Clinical assessment
• Assess level of consciousness using coma score.
• Determine the presence of severe anaemia
• Determine presence of respiratory distress

Assessment Tasks For Cerebral malaria cont’d
• Determine hydration status
• Assess for renal insufficiency
• Assess for evidence of Disseminated Intravascular Coagulopathy (DIC)
• Assess for stiff neck and do lumbar puncture

Assessment Tasks For Cerebral malaria cont’d
ii. Laboratory Tests
• In children with altered consciousness, start treatment for both malaria and
meningitis until lumbar puncture results exclude meningitis
• Do blood glucose to rule out hypoglycemia

Assessment Tasks For Severe Anaemia (1)
i. Clinical assessment
• Examine for pallor on the palms and conjunctiva
• Determine presence of respiratory distress
• Assess for shock
• Assess for evidence of Disseminated Intravascular Coagulopathy
• Assess for evidence of cardiac failure
• Pulmonary oedema

Assessment Tasks For Severe Anaemia (2)
ii. Laboratory test.
• Determine haemoglobin levels, blood group and cross match where applicable

Assessment Tasks For Hypoglycaemia
i Clinical assessment
• Assess the level of consciousness
ii Laboratory test
• Determine the blood glucose level

Part 2
Pre-referral management

Pre-referral treatment (1)
• Treatment for suspected severe malaria provided at the
peripheral facility where IV infusion cannot be given as
patient waits for referral
• Initiate treatment with IM artesunate
• If patient has altered consciousness, administer
antibiotic for meningitis (e.g. Ceftriaxone)
Pre-referral Treatment
• Treatment for suspected severe malaria
provided at the peripheral facility where IV
infusion cannot be given as patient waits for
referral
• If patient has altered consciousness, administer
antibiotic for meningitis (e.g. Ceftriaxone)
• Initiate treatment
with IM artesunate
44
Pre-referral Treatment cont’d
Transport child lying on the side
Health worker should accompany patient
Investigate mode of transporting patient
All attempts should be made to refer patients
• Give clear referral note with clinical
picture and medications given and doses
• If investigations were done, send results
or slides along with patient
45
ARTESUNATE PRODUCT DESCRIPTION
• Artesunate dispensed as
Artesunic powder
• Dissolved in sodium
bircarbonate (5%) to form
sodium artesunate
• Solution then dissolved in
5mls of normal saline or
5% dextrose
• USE OF WATER FOR INJECTION
NOT RECOMMEDED
Artesunate
powder
Bicarbonate
ampoule
Saline
Solution
+
47

• Administer treatment in the following order of
preference depending on availability:
IM artesunate
Rectal Artesunate (suppositories)
IM Quinine
IM Artemether
ARTESUNATE PRODUCT DESCRIPTION
• Artesunate dispensed as
Artesunic powder
• Dissolved in sodium
bircarbonate (5%) to form
sodium artesunate
• Solution then dissolved in
5mls of normal saline or
5% dextrose
• USE OF WATER FOR INJECTION
NOT RECOMMEDED
Artesunate
powder
Bicarbonate
ampoule
Saline
Solution
+
47
Pre-Referral dosage of IM
artesunate
• Administer 3.0mg/kg for children < 20kg ,
then refer
• Administer 2.4mg/kg for children > 20kg
and adults, then refer
48

Rectal Artesunate
• Rectal artesunate is presented as suppositories
• Administer a single dose
• If expelled before 30 mins, insert a second one
• For young children hold the buttocks for 10 mins to
retain the suppository
• For patients above 6 yrs, Rectal artesunate is not
recommended

Dose of IM quinine
• Quinine must be diluted to a maximum of
• 50mg/ml in children
• 100mg/ml in adults before IM administration
• Loading dose for IM quinine is 20mg/kg in ALL age groups ( to a maximum of
1200mg)
• A maximum of 3ml to be injected at one site

Disadvantages of IM quinine
• Risk of sterile abscesses
• Relatively poor absorption of quinine (less drug available) compared to IV or
oral quinine – the illness may worsen

IM Artemether
• IM artemether is fat soluble
• It is provided in dilution form
• Administer as a stat dose
• Administer IM 3.2mg/kg/body wt
• Refer patient after administration

Part 3
In patient management of severe malaria

IM Artemether
• IM artemether is fat soluble
• It is provided in dilution form
• Administer as a start dose
• Administer IM 3.2mg/kg/body wt
• Refer patient after administration
STEP 1. WEIGH
THE PATIENT
STEP 2. CHECK
VIALS NEEDED NOTE:
• Each vial require separate reconstitution,
dilution and administration
• Reconstitute immediately before use 54

STEP 3: RECONSTITUTE
A
B
C
D
STEP 4: DILUTION
C
B
A
D
VOLUME FOR DILUTION IV IM
Bicarbonate Solution Volume 1ml 1ml
Saline Solution 5ml 2ml
Total Volume 6ml 3ml
Artesunate 60mg solution
concentration
10mg/ml 20mg/ml
55

STEP 5. CALCULATE DOSE
Less than 20 kg(IV) Less than 20kg (IM)
More than 20 kg(IV) More than 20kg (IM)
56

Part 3
Inpatient management of Severe Malaria
STEP 1. WEIGH
THE PATIENT
STEP 2. CHECK
VIALS NEEDED NOTE:
• Each vial require separate reconstitution,
dilution and administration
• Reconstitute immediately before use 54
STEP 3: RECONSTITUTE
A
B
C
D
STEP 4: DILUTION
C
B
A
D
VOLUME FOR DILUTION IV IM
Bicarbonate Solution Volume 1ml 1ml
Saline Solution 5ml 2ml
Total Volume 6ml 3ml
Artesunate 60mg solution
concentration
10mg/ml 20mg/ml
55
STEP 5. CALCULATE DOSE
Less than 20 kg(IV) Less than 20kg (IM)
More than 20 kg(IV) More than 20kg (IM)
56
6. ADMINISTER
• 3 parenteral doses over 24 hrs
• Continue parenteral treatment (1 dose
daily) until patient can take oral medication
(Max 7 days)
• Mandatory full 3-day course of ACT as soon
as patient can take oral medication
– 1st dose of ACT btwn 8 & 12 hrs after last
injection
• Evaluate patients progress continuously
7. DOSING SCHEDULE
57

Quinine administration in children
• Loading dose of 20mg/kg in 15ml/kg of 5% dextrose or normal saline to run
over 4 hours
• Omit loading dose if any quinine has been given in the previous 24 hours
• 8 hours from commencement of initial dose, give 10mg/kg quinine in 10ml/kg
of 5% dextrose or normal saline to run over 4 hours
• Repeat 10mg/kg infusion every 8 hours until the patient is able to sit up and
take oral medication

Quinine administration in adults
• Loading dose of 20mg/kg (maximum of 1200mg)in 5% dextrose or normal
saline to run over 4 hours
• Omit loading dose if any quinine has been given in the previous 24 hours
• Maintain with 10mg/kg (maximum of 600mg) infusion 8 hourly until the
patient is able to take oral medication

Follow on treatment after IV quinine
• Once all patients are able to take oral medication:
• Give a full course of artemether-lumefantrine
OR
• Continue oral quinine at 10mg/kg (max 600mg) 8 hourly for a total of 7 days of
treatment

Supportive treatment
• Hypoglycaemia – IV or oral glucose (10% glucose 5
ml/kg)
• Convulsions
• diazepam 0.3mg/kg IV or 0.5 mg/kg rectally
• Phenytoin or phenobarbitone
• Severe anaemia – transfuse
• Fluid and electrolyte balance
• Fever and nursing care

Frequent questions
1. Would you give Artesunate / IV Quinine to a child with severe malaria and
Hb of 3g/dl?
2. Would you give fluid to a child with Hb of 3g/dl before giving a blood
transfusion?

Answers
1. Yes, Artesunate or quinine must be given as soon as possible while waiting
for blood transfusion.
2. Yes, children with severe malaria and severe anaemia can be given fluids
while waiting for blood transfusion.

Case studies

Case study 1
• A 2-year-old girl from an area with stable malaria develops fever and soon
has a brief convulsion. The family lives in a remote community away from
the city. Initially the mother gave the child a teaspoonful of herbal
concoction. Later, on the evening of the same day, the child's speech
became less comprehensible and shortly afterwards she was no longer
responding to any call. It took the mother 4 hours to get to the nearest
hospital and the child remained unconscious until they got there. In
addition to the loss of consciousness, she was found on examination to be
severely pale with a temperature of 38.5°C.
• What key information is provided in this history?
• What signs of severe disease can you identify?
• How should this child’s illness be classified
• What urgent treatment would you give
• List 4 important laboratory tests to be done.
• What specific treatment would you give this child?

Case history 2
• The place: a rural clinic in a hyper endemic P. falciparum area.
Various antimalarial drugs are available, but intravenous infusions
cannot be given.
• A child aged 20 months became feverish two days ago and has
vomited several times today. One hour ago the child had a
convulsion, described by the mother as a repetitive twitching of
the limbs and mouth, followed by unresponsiveness for a few
minutes. The child is now febrile (39°C), conscious, and withdraws
promptly from any painful stimulus. A thick blood film shows P.
falciparum rings “860/200”WBC. The child repeatedly vomits any
antimalarial drug given by mouth.

Case study 2 cont’d
• Does the child have cerebral malaria? Why?
• What should you do about the convulsions?
• What treatment will you give? State dose & route of
administration.
On the second day of treatment, the child was brought back to the
clinic. There was little change; he was still febrile and the
parasitaemia was similar to the previous day.
• Does this suggest that the child has drug resistant malaria?
The child went on to complete a full course of AL. By the 3rd day, he
was well and aparasitaemic.
At the end of 7 days a further blood test showed gametocytes.
• What should be done about the gametocytes present in the blood
after treatment?

…Case study 3 cont’d
i. What are the differential diagnoses?
ii.Was the patient right to think he was immune to malaria?
iii.The thick blood film shows P falciparum 3900/200 WBC and
the thin blood film shows that 26% of the red cells are
parasitized. What else would you look for in the thin blood
film?
iv.What else would you do to investigate the bleeding tendency?
v.What treatment is needed for the bleeding?

Case study 3
• 4. A four-year-old girl is brought to the outpatient department of your hospital by her mother, late in the
evening. The child was well until yesterday morning (36 hours ago), when she began to have fever. Yesterday
she took meals but seemed restless; today she has refused food, and only drank a little. The mother says the
child had a “fit” this morning; she regained consciousness immediately. For the past few hours the child has
been increasingly drowsy, and for the last hour has been unconscious.
• On examination the child is well nourished, unconscious and not dehydrated. The axillary temperature is
40.2°C; pulse 120 beats/min, regular; blood pressure 90/70 mmHg. No neck stiffness. Some yellowish sticky
fluid is seen filling the external part of the left ear. There was no rash.

Case study 3
i. What essential laboratory tests will you perform to guide your
management of the patient?
ii. Why does the blood glucose test have priority in this case?
iii.Should you wait for the blood glucose test if it will take more than 2 hours?
iv.So what should you do?
In this child, a stix test on finger-prick capillary blood revealed a glucose level
of 1.0 mmol/L (18 mg/dl). 50% dextrose was given intravenously but the
child remained unconscious. What does this suggest?
• The child has P falciparum parasitaemia 465/200 WBCs with
hypoglycaemia.

Case study 3 cont’d
v. Does this exclude a diagnosis of meningitis?
vi. If stiff neck is absent is it necessary to do a lumbar puncture?
vii. Does clear & colourless cerebrospinal fluid exclude
meningitis?
viii. what antimalarial drug will you give the patient? Give the
dose and route.
ix. If haemoglobin is 6.3.mg/dL. What will you do?
x. At what point would you give a blood transfusion?
xi. If blood transfusion is necessary, how would you give the
blood?

xii. What clinical observations would you maintain during
management?
xiii. What laboratory tests would you repeat, and frequency?
xiv. What should be looked for after the child has recovered?

Case study 5
• The place: A country where P. falciparum malaria is transmitted in forested
areas but not in the main cities.
• A woman aged 25 years is brought to the outpatient department of the
central hospital in the capital. She is a local resident, the wife of a business
executive, and is in the seventh month of her pregnancy.
• The patient became ill five days ago, with chills, sweating and headache. An
antibiotic was prescribed and her condition seemed to improve, but
yesterday she developed rigors and persistent vomiting. A blood film at the
local clinic revealed malaria parasites, and oral quinine (600 mg every 8
hours) was prescribed. She took two doses.
• Today she has been referred to your hospital because of confusion.
Examination reveals a semiconscious woman who is unable to talk. She
withdraws her hand from a painful stimulus but cannot localize a stimulus
applied to the sternum or forehead. There is no neck stiffness, jaundice,
pallor or rash. Axillary temperature is 39°C, pulse 90 beats/min, blood
pressure 110/70 mmHg. The uterine fundus is palpable (26 - 28 weeks) and
the foetal heart can be heard.

…Case history 5
i) What other questions would you ask the patient’s relatives?
ii) What tests are urgently required?
ii) If the blood glucose is 1.2 mmol/L, what treatment will you give?
iii) If the blood film shows P falciparum 465/200 WBCs, and the cerebrospinal fluid is normal except for low
glucose, what antimalarial drug would you administer and by what route?
iv) Would you prefer an alternative to quinine because of the pregnancy?
v) Would you give a loading dose of quinine?
vi) What nursing procedures are important during this treatment?

Case history 5 cont’d
i. What other questions would you ask the patient’s relatives?
ii. What important tests should be done?.
• a)
• b).
• c).
• d).
iii.If the blood glucose is 1.2 mmol/L, what treatment will you give?
iv.If the blood film shows P. falciparum 465/200 WBCs, and the cerebrospinal
fluid is normal except for low glucose, what antimalarial drug would you
administer and by what route?

v. Would you prefer an alternative to quinine because of the
pregnancy?
vi. Would you give a loading dose of quinine?
vii. What nursing procedures are important during this
treatment?
After 6 hours, the patient becomes increasingly restless. The
respiratory rate increased to 40/minute. The blood glucose
level is normal. Under these conditions, what special
observations would you make?
• a)
• b)

Thank you
55

Division of National Malaria Programme – Komesha Malaria, Okoa Maisha
Malaria Free KENYA
Elimination
SMEOR
Case Mgmt SBC
Vector Control
MIP
Prog
Mgmt
56

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