Additional Management And Supportive Measures

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Reduce fever:

  • Tepid sponging with lukewarm (not cold) water
  • Give an antipyretic (paracetamol 10 mg/kg; 6 to 8-hourly) as required until fever is reduced

Take 8 immediate measures:

  1. Start resuscitation, particularly maintenance of a patent airway.
  2. Establish IV line.
  3. Make a thick blood smear for immediate malaria parasite count, {if microscopy is not available, an mRDT may be useful to indicate whether malaria infection is present or not)
  4. Classify the degree of dehydration, assess patient's fluid requirements and correct accordingly.
  5. Control fever if the axillary temperature is 38.5oC or above: Tepid sponge, fanning and oral or rectal paracetamol (15 mg/kg every 4 to 6 hours).
  6. Control convulsions: maintain airway, treat with rectal diazepam (0.5 mg/kg) or slow IV diazepam (0.3 mg/kg, maximum 10mg in an adult), or paraldehyde 0.1 ml/kg IM. Remember to correct any hypoglycaemia or hyperpyrexia in a convulsing patient.
  7. Detect and treat hypoglycaemia: hypoglycaemia can be induced by high parasitaemia, fasting and quinine therapy. Hypoglycaemia can recur, especially in pregnant women and children. If blood glucose 3 mmol/l or 54 mg/dl; give 1 ml/kg of 50% dextrose IV, diluted with an equal volume of 0.9% saline or 5% dextrose, give slowly over 3-5 minutes, and check blood glucose after 30 minutes and as required after treatment. Follow with 10% dextrose infusion at 5 ml/kg/hr. If there is no test for blood glucose, treat as if the patient is hypoglycaemic.
  8. Start intravenous or intra-muscular artesunate. Dosage schedule is provided from section 2.2.2.2 of MSTG below. If intravenous or intra-muscular artesunate is unavailable, use intravenous or intra-muscular quinine.

 

LOOK FOR AND DEAL WITH THE FOLLOWING 8 COMPLICATIONS

  1. Shock: If cold peripheries, delayed capillary refill, or Systolic BP <50 mmHg in children 1 - 5years or <80 mmHg >5 years, suspect Gram-negative septicaemia. In such cases take blood samples for culture. Give parenteral broad-spectrum antimicrobials. Correct fluid disturbance, and then continue with maintenance fluid as follows: for children weighing <10 kg, give 4 ml/kg/hr; for children weighing 10 - 20 kg, give 40 ml/hr. plus additional 2 ml per kg for each kg of weight in excess of 10 kg; for children weighing >20 kg, give 60 ml/hr., plus additional 1 ml per kg for each kg of weight in excess of 20 kg. Give oxygen if possible.
  2. Severe anaemia: Consider the need for blood transfusion: Assess the degree of pallor (no pallor, some pallor or severe pallor - look especially at palms of hands, also mucous membranes). Assess signs that increase the danger of severe anaemia - respiratory distress, altered consciousness, shock and hyper-parasitaemia. Note: The decision to transfuse with blood should not only be based on low laboratory values, but on a full assessment of the patient**. As a guide, all patients with PCV<12% or Hb<4 g/dl should be transfused, whatever the clinical state; those with any of the above danger signs may be transfused even if PCV is 13-18% or Hb 4-6g/dl. Transfuse packed red cells in most cases; in shock or severe acidosis, use whole blood. The volume transfused should be 20 ml/kg.
  3. Metabolic acidosis (deep, fast breathing): exclude or treat hypoglycaemia, hypovolaemia and gram negative septicaemia. Give isotonic saline  20 ml/kg of body weight rapidly or screened whole blood 10 ml/kg if PCV <18% or  Hb<6 g/dl. Consider lactic acidosis and enquire whether the patient has been taking ART (lactic acidosis is a side effect of stavudine).
  4. Spontaneous bleeding or coagulopathy: If patients have underlying malnutrition, concomitant hepatic obstruction and bile salt excretion defects or prolonged fasting for more than 3 days, transfuse screened fresh whole blood, give Vitamin K 10 mg IV slowly once a day for 3 days. For Children give 2 - 3 mg/day slow IV. Vitamin K injections should not be given to "all" severe malaria patients with spontaneous bleeding, the risks and benefit of Vitamin K administration should be considered. Serious adverse events of Vitamin K injection include hypotension, difficulties in breathing, bradycardia or anaphylaxis.
  5. Acute pulmonary oedema in adults: prevent by avoiding excessive rehydration. Treatment: prop patient up; give oxygen. Stop IV fluids if pulmonary oedema is due to over-hydration, give a diuretic (Furosemide IV 40 mg for adult and 0.5 - 1 mg/kg/dose for children).
  6. Acute respiratory distress syndrome: supportive treatment +/- ventilation.
  7. Acute kidney injury in adults: detect this by monitoring fluid balance. Identify and correct any dehydration or hypovolaemia. Maintain strict fluid balance. Consider peritoneal dialysis if oliguria persists beyond a few days.
  8. Common infections and other conditions that present like severe malaria: Perform urinalysis, lumbar puncture (unless contraindicated), blood culture if possible, and chest x-ray.

 

Box 3: Monitor the Following 8 Observations: 

Where possible use Critical Care Pathways (CCPs).

  1. Level of consciousness (using coma score)
  2. Vital signs every 4 hours (temperature, pulse, respiration, blood pressure)
  3. Fluid balance (urine volumes, intake volumes - IV and oral - puffy eyes, chest crepitation, elevated jugular venous pressure)
  4. Increasing anaemia (pallor, heart failure with increasing liver size)
  5. Occurrence of convulsions - see item 2 in previous Box
  6. Blood glucose every 4 hours’ while unconscious and also if convulsions occur
  7. [Hb]/Packed Cell Volume - at least daily, or more often if anaemia is suspected
  8. Ability to suck, drink, eat, sit and walk -measures of overall strength