Page 997 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

728 PART 5: Infectious Disorders

■ SUPPORTIVE TREATMENT cultures should be repeated (as it should be performed in all cases of

Convulsions: Seizures in cerebral malaria should be treated with severe malaria), and appropriate broad-spectrum antibiotics admin-
istered to cover the possibility of bacterial sepsis. If inotropes are
rectal diazepam, intravenous lorazepam, paraldehyde, or other stan-
dard anticonvulsants, after high flow oxygen and appropriate airway necessary, dopamine has been used safely in malaria, and dobutamine
and norepinephrine may also be used though there is little experience
management have been initiated. In a small study, prophylactic
phenobarbitone reduced seizures after admission of adults with with them in severe malaria. Epinephrine should be avoided as it
induces serious lactic acidosis.
39
cerebral malaria. A study in children using a single intramuscular
69
Aggressive fluid resuscitation in the management of severe malaria
dose of 20 mg/kg reduced seizures but increased mortality, pos- without hemodynamic shock, in both children and adults, is not recom-
sibly through respiratory depression caused by an interaction with
diazepam in a site where mechanical ventilator support was unavail- mended. In a recent trial evaluating fluid bolus therapy (20-40 mL/kg) in
70
3141 African children with “compensated shock” (shock without severe
able. Prophylactic anticonvulsant therapy is therefore currently not
recommended. hypotension), of whom 57% had severe malaria, mortality was 110/1202
(9.2%) with fluid bolus therapy, and 34/591 (5.8%) without a fluid bolus,
46
Anemia: Benefits of blood transfusion should outweigh the risks an increased relative risk (95% CI) of dying of 1.59 (1.10-2.31). In this
(especially those of HIV and other pathogens), which differ between report, it is unclear if pulmonary edema increased intracranial pressure
regions where patients with severe malaria are managed. There is no or both complications occurring after fluid bolus therapy were respon-
clear evidence supporting specific hemoglobin levels below which a sible for this increased mortality. In adults with severe malaria, a subset
transfusion is vital, and different figures are quoted in reviews and of patients will have pulmonary capillary leakage. There is currently no
guidelines. In adults, the threshold for blood transfusion is com- early marker to identify this group of patients in whom aggressive fluid
monly set at a hematocrit below 20%, and in African children at therapy can obviously be harmful especially in settings where endotra-
a hemoglobin level below 4 g/dL (absolute threshold), or 5 g/dL if cheal intubation and mechanical ventilation are not feasible.
there is coexisting respiratory distress, impaired consciousness, or Blackwater Fever: Patients with “coca-cola” colored or red urine
hyperparasitemia.
should be adequately rehydrated. Bicarbonate therapy may be consid-
Acidosis: Adequate antimalarial treatment is essential to treat the ered, though there are no clinical trials evaluating this.
underlying cause of acidosis (see above). Adequate fluid manage- Rhabdomyolysis can complicate severe malaria. Plasma CPK concen-
ment guided by appropriate measurements, and possibly exchange trations are usually elevated, but overt rhabdomyolysis is rare.
transfusion, can be beneficial. Antiadhesive adjunctive treatments are Other Supportive Treatments: Good nursing care is essential, with
being trialed. There are no trials evaluating bicarbonate therapy. The particular attention to fluid balance, management of the unconscious
“surviving sepsis” guidelines advise bicarbonate administration only patient, and detection of potentially lethal complications such as
if the blood pH falls below 7.1, but these may not necessarily apply hypoglycemia. Endotracheal intubation in the unconscious patient
to patients with severe malaria. 71,72 The use of dichloroacetate to treat may be necessary to protect the airway. Many resource poor coun-
lactic acidosis in severe malaria has only been studied in trials estab- tries are reaching a stage where basic ICU care in regional hospitals
lishing safety and pharmacodynamic efficacy and not with mortality is feasible. These developments also have great potential to reduce
as an outcome measure. 73,74
malaria mortality further.
Acute Kidney Injury: Renal replacement therapy can save lives in those
cases with acute kidney injury, a common complication in adult
patients, having an untreated mortality of over 70%. Hemofiltration,
when available, is superior to peritoneal dialysis in terms of mortality KEY REFERENCES
and cost-effectiveness. 42
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infections. Mechanical ventilation can be life saving, but is often on seizure frequency and mortality in childhood cerebral malaria:
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