SIMPLE STEP-BY-STEP GUIDE to the DIAGNOSIS and MANAGEMENT of SEVERE MALARIA

District hospital level Severe Malaria is a Medical Emergency

High index of suspicion

• Suspect malaria in any patientpresenting with fever or historyof fever who lives in a malariaareaorvisitedamalariaarea.

Confirm the diagnosis of malaria• Urgentlyperformarapidmalariadiagnostictest.

and/or

• Sendbloodspecimeninapurpletoptubetolaboratoryformalariasmears. Mark the lab requestformasURGENT andchasetheresults.

• Thetreatmentofmalariaisurgent andanydelaysindiagnosisandtreatment may result in severemalaria.

URGENT!!

• Commence parenteral antimalarial treatment

IVartesunateprefered(ifavailable),Dosing(giveat0,12hoursand24hours):children<20kg:3mg/kgbwperdose);children(>20kg)andadults:2.4mg/kgbwperdose. (see Artesunate poster for details)

OR

IVquinine–loadingdosestrictlyfollowedbymaintenancedosesbothgivenasaSLOWIVinfusionover2-4hoursanddosedstrictlyaccordingtobodyweight.(see details below)

• NB: Severe malaria cannot be treated effectively with oral antimalarial drugs: Coartem® or quinine tablets.

URGENT!!

As soon as severe malaria is diagnosed the following special investigations should be ordered urgently.

• FBC,ESRand/orCRP• Malariasmears• Urea,electrolytes,Creatinine• Liverfunctiontests 8mEq/Lorplasmabicarbonate <15mmol/Lorvenousplasmalactate>5mmol/L

• Blood culture, if indicated(should always be done in very sick patients, especially those with severe hypotension or shock)

• Coagulationstudies(ifsignsofabnormalbleeding)

• Chest X-ray (if indicated, e.g.respiratorydistress)

URGENT!!

The following monitoring is required:

• Routinevitalsignsobservations(TPRandBP),4hourly.

• Strictinput/outputrecordoffluids

• Bloodglucose(2to4hourly)• Haemoglobin(daily)• Malariaparasitecount(daily)• Nurses must report

abnormal observations immediately to doctor.

URGENT!!

Chase and obtain the results of theinitial laboratory blood tests (step3) within 2-4 hours of commencingtreatments.

Regularlyreviewthepatientlookingforthefollowingcomplications:• Severeanaemia(Hb≤6g/dl)• Septicaemia(highwhitecellcount).• Metabolicacidosis(pH<7.25,and/orhighaniongap,and/orplasmabicarbonate<15mmol/L,and/orvenouslactate>4mmol/L).

• Renalfailure(creatinine>260µmol/L).

• Liverfailure(severederangementofliverenzymes)

Make a clear plan for the effectivemanagement of each complicationsidentified.

Note: Antimalarial medication onlykillsmalaria parasites in the blood, itdoes not correct the complications.Complications must be activelymanaged.

URGENT!!

Consider contacting a referralhospitalearly(ifseverelyilland/orpresentseverecomplicationse.g.

• Cerebralmalaria(unconsciousness).

• Respiratorydistresssyndrome• Shock(severehypotension).• Metabolicacidosis• Septicaemia• Renalfailure• Liverfailure• Disseminatedintravascularcoagulation(DIC)

CRUCIAL!!

• Iftransfertoreferralhospitalnotnecessarythepatientshouldbereviewedtwicedailyinthewardwithmonitoringrecordsandresultsofinvestigationsuntilclinicalconditionimprovesandstabilizes.

• Bloodtests(FBC,Malariaparasites,U/E/creatinine,LFT)shouldberepeatedatleasteverytwodaysandpatientreviewedwiththeresults.

• Monitorurineoutput.

• Patientshouldshowclinicalimprovementbyday3oftreatment.Ifnot,thereferralhospitalshouldbecontactedtodiscussthepatient’scondition.

URGENT!!

Consider ancillary treatments if indicated e.g.

• Oxygen• IVFluids• Temperaturecontrol(paracetamol,tepidsponging)

• Anticonvulsants (hypoglycaemiamust always be ruled out beforegivinganticonvulsants)

• Pipes(CVPline,urethralcatheter,NGtube)

• Assistedventilation• Antibiotics recommended in allchildren with severe malaria-secondarybacterialinfectionsarecommon.

URGENT!!

• Admit patient to:ICUOrhighcarewardOrhighcarebed

• Caution: Severe malaria patients need intensive nursing so they should not be managed in a general ward

URGENT!!

If malaria is confirmed, re-assess the patient for signs of severe malaria.

Features of Severe Malaria:• Clinical History:ConvulsionsPersistentvomitingSeverediarrhoea‘Black’urine

• Physical Examination:Prostration(severegeneralbodyweakness)Impairedconsciousness(sleepiness,confusion,coma)RespiratorydistressCirculatorycollapse(hypotension,shock)JaundiceSeverepallorAbnormalbleeding

• Basic (Side Room) Tests:Glucometer(HGT)glucose<2.2mmol/LHaemoglobinmeter(Hb=≤6g/dL)Urinedipstix(haemoglobinuria)

Ifanyoneoftheabovefeaturesispresent,diagnoseandtreatasseveremalaria.

STEP 1: Diagnose Malaria

STEP 7: In-patient Monitoring STEP 8: Ancillary Treatments

A long and healthy life for all South Africans

STEP 10: Continuation of CareSTEP 9: Patient Review STEP 6: Collaboration / Referral

STEP 2: Assess Severity STEP 4: Antimalarial Treatment STEP 5: Hospital AdmissionSTEP 3: Special Investigations

How to treat severe (complicated) malaria with IV Quinine:Calculate doses strictly according to body weight.

Start with a loading dose:20mg/kg in 5% Dextrose drip, run slowly x4 hours.

Continue with maintenance doses:10mg/kg in 5% dextrose drip 8 hourly. Each dose to run slowly x4 hours.

If renal failure, decrease main-tenance doses by 1/3 to 1/2 from day 3.

Change to oral treatment as for uncomplicated malaria as soon as clinical condition improves and patient can tolerate orally.

Compiled by the National department of health 2016