A 35 year old man, recently returned from an African trek, is admitted with coma, severe hypoxia and dark urine.  A thick film of blood shows malarial parasites.  Outline your management over the first 48 hours

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College Answer

This is a medical emergency with a potentially high mortality due to plasmodium falciparum. Initial management of acute severe malaria with these features should include: 
(a) Airway- the patient is unconscious so the airway will need to be secured.              - 
(b) Breathing - hypoventilation associated with the cerebral obtundation will necessitate IPPV 
to normalise PC02•  ARDS is common in this setting and will require titration of Fi02, PEEP 
and ventilatory mode (?PRVC,IRV etc). 
(c) Circulation - shock is not uncommon with severe malaria. Volume loading in clinical studies is usually counterproductive with associated worsening hypoxia. Inotropic support is usually indicated and renal failure my require CVVHD. 
(d) Diagnosis - secondary infection is uncommon, but other precipitants of deterioration should 
be excluded eg.. pneumonia. 
(e) Definitive therapy with antimalariais. Depending on known sensitivities from the area 
visited - quinine sulphate may be the treatment of choice  (IV  loading dose followed by eight hourly doses). 
(f)  Invasive monitoring. 
(g) Metabolic support- hypoglycaemia is common. 
(h) Exchange transfusion- not medically justified.

Discussion

This question vaguely resembles Question 20 from the second paper of 2009. However, the answer there is not set up in a "systematic" fashion. Here I will attempt a systematic approach.

  • Attention to the ABCS, with management of life-threatening problems simultanous with a rapid focused examination and a brief history
  • Airway
    • The patient is comatose. This mandates intubation.
  • Breathing/ventilation
    • Increased minute volume to compensate for metabolic acidosis
    • Adequate PEEP and FiO2 to maintain normoxia in the face of poor gas exchange, likely due to pulmonary involvement form malaria or aspiration due to obtundation
    • Lung protective strategy (given the frequency of ARDS in this setting)
  • Circulatory support
  • Supportive management
    • Sedation to comfort
    • Electrolyte correction
    • CVVHDF support of renal failure is a feature
    • Enteral feeding (given the prodorome likely featured a period of poor oral intake and vomiting)
    • Transfusion and blood product replacement to correct coagluopathy
  • Monitoring
    • Invasive hemodynamic monitoring with arterial line as minimum
  • Specific investigations
    • Confirmation of parasite species by PCR
    • Monitoring or organ dysfunction:
      • ABG
      • EUC /CMP
      • LFTs
      • Coags and fibrinogen
  • Specific management
    • 2010 guidelines statement by the WHO suggests the following management strategy for severe falciparum malaria:
      • Artemisinin derivatives are first line, as per the the AQUAMAT trial; previously to 2010 the guidelines did nto have enough evidence to recommend artsunate over quinine.
      • Quinine is second-line these days.

References

World Health Organization. "Severe falciparum malaria." Transactions of the Royal Society of Tropical Medicine and Hygiene 94 (2000): 1-90.

 

Riddle, Mark S., et al. "Exchange transfusion as an adjunct therapy in severe Plasmodium falciparum malaria: a meta-analysis." Clinical infectious diseases34.9 (2002): 1192-1198.

 

Reyburn, Hugh. "New WHO guidelines for the treatment of malaria." BMJ 340 (2010).

(the actual revised guidelines are available online for free)

 

Dondorp, Arjen M., et al. "Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial." The Lancet 376.9753 (2010): 1647-1657.

 

Trampuz, Andrej, et al. "Clinical review: Severe malaria." CRITICAL CARE-LONDON- 7.4 (2003): 315-323.

 

Maitland, Kathryn, et al. "Response to volume resuscitation in children with severe malaria*." Pediatric Critical Care Medicine 4.4 (2003): 426-431.

 

Maitland, Kathryn, et al. "Mortality after fluid bolus in African children with severe infection." New England Journal of Medicine 364.26 (2011): 2483-2495.