Severe Malaria

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This is a life-threatening condition, and the goal of management is to prevent death. Therapy should be initiated without delay.

Check for signs of:

• prostration, i.e. if the patient is unable to stand or sit or feed independently, (children will be unable to breastfeed)
• persistent vomiting
• the slightest sign of alteration in consciousness which may indicate cerebral malaria (refer to the Coma Scale).

Complications include any of the following:

• Cerebral malaria
• Bleeding tendencies
• Severe anaemia (Hb< or=6g/dl); (Hb < 7.5gldl for non-immune patients)
• Hyperpyrexia
• Jaundice Shock
• Severe haemoglobinuria
• Hyperparasitaemia (>5% in non-immune patients)
• Acute renal failure
• Respiratory distress
• Hypoglycaemia

Treatment of severe/complicated malaria must be parenteral, and the medicine of choice is artesunate while quinine will remain a usable option.

Treatment at Health Centre

At primary level, parenteral therapy with artesunate injection must be commenced by IM administration or, if it is practical, by IV infusion before the patient is referred. Treatment is initiated by a loading dose of artesunate or quinine.

Medicine	Dose	Frequency	Duration
Artesunate im/iv	2.4mg/kg	Dose 1: stat Dose 2: after 12 hours Dose 3: after 24 hours Dose 4 onwards; daily	minimum 3 doses before switch to oral upon improvement

Dosage at 2.4 mg/kg (comprehensive dosage schedule}.

Weight	5kg-25kg	26kg-50kg	51kg-75kg	76kg-100kg
60mg/vial	1	2	3	4

Instructions for reconstitution and dilution of parenteral Artesunate for intravenous (IV) use.

Reconstitute the artesunate powder with the 1ml of sodium bicarbonate ampoule provided. The solution will initially look cloudy. Wait for 1 minute for it to clear. Discard the solution if it does not clear. Add 5 mls of 5% dextrose in water or normal saline to the reconstituted solution. The resultant 6ml solution will contain 10mg per ml Artesunate. Check the dose from table below to administer.

Dosing Schedule

• Give a minimum of 3 parenteral doses of Artesunate before changing to oral treatment, even if the patient is able to take oral medication early
• Prepare a fresh solution for each injection
• Intravenous injection is given as slow bolus, about 4 mls per minute
• Discard any unused solution.

Day 1	Day 1	Day 2	Day 3	Day 4	Day 5	Day 6	Day 7
Stat Dose 1	12 hrs Dose 2	24 hrs Dose 3	Daily Dose 4	Daily Dose 5	Daily Dose 6	Daily Dose 7	Daily Dose 8

Check the dose to give intravenously on table below:

Weight	Dose (mg)	Volume(ml)
5-8 kg	20	2
9-12 kg	30	3
13-16 kg	40	4
17-20 kg	50	5
21-25 kg	60	6
26-29 kg	70	7
30-33 kg	80	8
34-37 kg	90	9
38-41 kg	100	10
42-45 kg	110	11
46-50 kg	120	12
51-54 kg	130	13
55-58 kg	140	14
59-62 kg	150	15
63-66 kg	160	16
67-70 kg	170	17
71-75 kg	180	18
76-79 kg	190	19
80-83 kg	200	20
84-87 kg	210	21
88-91 kg	220	22
92-95 kg	230	23
96-100 kg	240	24

• Once the patient is able to take oral medication (and has received at least 3 doses) switch to oral Co-artemether for a full three-day course (see Table for Co-artemether course).
• If the patient is unable to take any oral medication continue with intravenous Artesunate for a total of seven days (see Table above ).
• Continue to evaluate the patient regularly for improvement or deterioration
• Continue supportive treatment and monitoring as required in all patients with severe

Preparing Artesunate for Intramuscular (IM) Use

RECONSTITUTE (Activate the Artesunate powder by mixing with 1ml of bicarbonate provided)

DILUTE (Add 2mls normal saline solution or 5% dextrose to each vial of Reconstituted Artesunate) CAUTION : Do not use water for injection

CHECK THE DOSE TO GIVE ON TABLE BELOW:

Weight	Dose (mg)	Volume(ml)
<5kg	10	1
5-8 kg	20	1
9-12 kg	30	2
13-16 kg	40	2
17-20 kg	50	3
21-25 kg	60	3
26-29 kg	70	4
30-33 kg	80	4
34-37 kg	90	5
38-41 kg	100	5
42-45 kg	110	6
46-50 kg	120	6
51-54 kg	130	7
55-58 kg	140	7
59-62 kg	150	8
63-66 kg	160	8
67-70 kg	170	9
71-75 kg	180	9
76-79 kg	190	10
80-83 kg	200	10
84-87 kg	210	11
88-91 kg	220	11
92-95 kg	230	12
96-100 kg	240	12

• Administer artesunate injection
• Intramuscular Injection volumes greater than 5mls should be spread over different injection

OR - IN ADULTS administer Quinine intravenously:

Medicine	Dose	Frequency	Duration
Quinine iv	20mg/kg (500ml infusion)   10mg/kg	loading dose: (do not exceed 1200mg)   dose 2: after 8 hours	over 4 hours

Intravenous Quinine loading dose of 20mg per kg body weight diluted in 500ml of Normal saline or 5% dextrose water infused over 4 hours. Do not exceed 1200mg of loading dose. After 8 hours subsequent doses should be administered at 10mg per Kg body weight diluted in Normal Saline or 5% dextrose water.

Additional Supportive measures for patients with severe malaria awaiting transfer:

• Maintain airway by appropriately positioning the patient in a left lateral position with the chin extended if patient is in a coma or convulsing.  Administer oxygen if available. Patients with pulmonary oedema should be propped up and given IV diuretics.
• Give IV 25% dextrose water for hypoglycaemia in children as 1ml 50% dextrose per kg body weight diluted 1:1 with water for injection. This can also be given orally or via nasogastric tube if IV access is not readily secured. Continue to breastfeed where the child is still able to do so.
• Parenteral anti-emetics can be administered in adults with persistent vomiting.
• Address hyperpyrexia through physical means such as tepid sponging and fanning. Antipyretics such as Paracetamol may be given where appropriate. 
• Treat convulsions with either intravenous or rectal diazepam where available. 

A CLEAR LEGIBLE REFERRAL LETTER STATING THE DATE, NAME OF PATIENT, BRIEF HISTORY, DIAGNOSIS AND THE PRE-REFERRAL TREATMENT GIVEN SHOULD ACCOMPANY THE PATIENT TO THE NEXT LEVEL OF CARE. COMPLETE THE MALARIA REFERRAL FORM

If IV Artesunate is unavailable, IV Quinine is the alternative for patients with severe malaria.