WHO guidelines and Indian guidelines on the treatment of complicated malaria

1. Treatment of Complicated Malaria
Treatment of Complicated Malaria

2.  It is an emergency!
 Main objective – prevent the patient from dying
 Secondary objectives – prevention of disabilities and prevention of recrudescence
 Parenteral therapy should be stated promptly
 IV route should be preferred over intramuscular

3. Components of Treatment
Clinical Assessment Additional and supportive
care
Antimalarial Chemotherapy

4. Clinical Assessment
 Airway, Breathing, Circulation
 Estimation of body weight
 IV cannula- blood glucose, PCV, parasitaemia, renal function(adults)
 GCS
 Lumbar puncture for CSF analysis in unconscious patients
 Plasma bicarbonate/venous lactate – assessment of pH
 Assessment of fluid balance to avoid under/over hydration

5. Antimalarial Therapy
Preferred Regimen
Artesunate- 2.4 mg/kg IV at 0,12 and 24 hrs and then once daily till the patient can take orally
In Children (Weight<20kg) : Artesunate – 3mg/kg to ensure equivalent drug exposure

6. Antimalarial Therapy
Alternative Regimen
 Artemether – 3.2mg/kg IM given on admission then 1.6mg/kg daily
 Quinine – 20mg/kg IV over 4hrs till a max dose of 1.4g (Loading Dose)
10mg/kg quinine salt 4hr infusions TID x 2 days,
then BD until the patient can take orally, or for a maximum
dose of 700mg (Maintenance Dose)
 Combine with Doxycycline (or Clindamycin in case of C/I)
 Artemether > Quinine (WHO)

7. Antimalarial Therapy
Follow on Treatment
 Once the patient can tolerate oral medication – full course of oral ACT:
Artesunate – 100mg BD x 3 days
Sulfadoxine – 1500mg
Pyrimethamine – 75mg
 Or Artemether + Lumefantrine
 Avoid ACT containing mefloquine in cerebral malaria due to neuropsychiatric complication

8. Cerebral Malaria(coma)
 Maintain airway and Intubate if necessary
 Exclude other treatable causes of coma (hypoglycaemia,bacterial meningitis)
 Insert a urethral catheter
 Aspirate stomach contents using a NG tube
 Avoid ancillary treatments such as glucocorticoids, heparin and adrenaline (epinephrine)

9. Hyperpyrexia
 Tepid sponging, fanning, cooling blanket
 Antipyretic drug (paracetamol)

10. Convulsions
 Maintain airway
 Slow IV Diazepam – 1.5mg/kg
 If not treated by 2 doses – SE : Phenytoin 18mg/kg loading and 5mg/kg maintenance for 48h
 In case of failure, phenobarbitone 15mg/kg IM/IV loading then 5mg/kg per day for 48h

11. Hypoglycemia (<2.2mmol/L)
 Measure blood glucose
 Give 50ml of 50% dextrose diluted with 100ml of any infusion fluidand infused over 3-5min
 Follow with an intravenous infusion of 200-500mg/kg per hour of 5% or 10% dextrose
 Continue monitoring blood glucose

12. Severe Anaemia (PCV < 15%)
 If hematocrit < 20% or Hb <7g/dL:
 Transfuse fresh whole blood or packed cells if pathogen screening of donor blood is available
 To avoid circulatory overload, give small IV doses of furosemide (20mg)

13. Acute Pulmonary Edema
 Keep the patient upright (bed adjustment)
 Give diuretic – Furosemide 0.6mg/kg IV
 Intubate and add PEEP/CPAP in life-threatening hypoxaemia
 If Pulmonary edema is due to overhydration:
 Stop all IV fluids and give furosemide
 Venesect 250mL of blood
 Use haemofiltration if there is renal impairment

14. Acute Renal Failure
 Exclude pre-renal causes like dehydration by clinical examination
 Fluid resuscitation if appropriate
 Renal replacement therapy - Peritoneal dialysis (haemofiltration or haemodialysis if available)

15. Spontaneous bleeding and coagulopathy
 Transfuse screened fresh whole blood (cryoprecipitate/fresh frozen plasma and platelets if
available)
 Vitamin K injection – 10mg slow IV

16. Metabolic acidosis
 Exclude or treat hypoglycaemia, hypovolaemia and Gram-negative septicaemia
 If there is evidence of dehydration:
 Fluid resuscitation – IV NS 0.9%
 Monitor BP, urine volume and JVP
 Improve oxygenation

17. Shock (‘algid malaria’)
 Suspect Gram-negative septicaemia
 Take blood cultures
 Start broad spectrum antibiotics immediately
 Correct hypovolemia with plasma expanders – Fresh blood,plasma,dextran 70 or polyglycans

18. Hyperparasitemia
 Consider exchange or partial exchange transfusion, manual or haemophoresis (e.g. > 10% of
circulating erythrocytes parasitised in non-immune patient with severe disease)

19. Complicated Malaria in Pregnancy
 Higher mortality in pregnant women rather than non pregnant women
 Patient should be transferred to ICU. Obstetric help should be sought
 Blood glucose should be monitored regularly
 Folic acid and Iron supplements during recovery from anaemia
 Parenteral antimalarial agents should be given at any stage of pregnancy (Artesunate – DOC)

20. Errors during Management
 Delay in starting antimalarial therapy (most serious)
 Failure to switch patients from parenteral to oral therapy after 24h, or as soon as they can take
oral medication
 Use of unproven and potentially dangerous ancillary treatment
 Failure to re-check blood glucose concentration in a patient who develops seizure or deepening
coma
 Delay in starting renal replacement therapy