Severe Malaria- Management

In a patient with Plasmodium falciparum asexual parasitaemia and no other obvious cause of symptoms, the presence of one or more of the features listed below classifies the patient as suffering from severe malaria.

Clinical presentation

• Prostration / extreme weakness

• Impaired consciousness

• Change of behaviour

• Convulsions

• Respiratory distress (due to lactic acidosis and/or pulmonary oedema)

• Jaundice

• Circulatory collapse / shock

• Vomiting everything

• Inability to drink or breastfeed

• Bleeding tendency / disseminated intravascular coagulation (DIC)

Investigations

In severe malaria, a blood slide is recommended as it quantifies parasitaemia. In severely ill patients receiving injectable antimalarial treatment, serial blood slide (BS) investigations help to monitor parasitaemia levels, confirm recovery, or rule out other serious conditions if clinical improvement is not observed.

• Blood film for malaria parasites

• Blood glucose estimation (especially in patients with altered consciousness)

• Haematocrit and/or haemoglobin estimation

• Lumbar puncture to exclude meningitis (if facilities are available)

• Serum creatinine or urea to assess kidney function

• Electrolytes for early detection of acute renal failure

• Full blood count with differential white cell count for additional diagnosis of other infections

• Blood gases, pH, and anion gap to diagnose acidosis

• Chest X-ray to assess pulmonary oedema or lobar consolidation

• Blood culture and sensitivity where feasible

Non-Pharmacological treatment

• Rapid assessment must be conducted, including evaluation of:

  • Airway

  • Breathing

  • Circulation

  • Coma

  • Convulsions

  • Dehydration status

Referral: If effective management of severe malaria and supportive care for complications is not possible, give pre-referral treatment and refer immediately to an appropriate facility for continued care.

Pharmacological treatment

Parenteral artesunate

Dosage

• 2.4 mg/kg body weight (IV or IM) given on admission (0 hour), then at 12 hours and 24 hours, for a minimum of 3 injections in 24 hours regardless of clinical recovery.

• Children weighing <20 kg: 3 mg/kg/dose (or higher), same schedule (0, 12, 24 hours).

After completion of parenteral therapy, complete treatment with a full 3-day course of Artemether + Lumefantrine (ALu) or another ACT.

• Consider broad-spectrum antibiotics for possible septicemia.

Administration of injectable artesunate

Injectable artesunate is available in 30 mg, 60 mg, and 120 mg strengths and is prepared in two steps:

Step 1

• Dilute powder with 1 ml of 5% sodium bicarbonate solution (provided in each box)

• Shake vigorously for 2–3 minutes until the solution becomes clear

Step 2

• For slow intravenous infusion (3–4 minutes): add 5 ml of 5% dextrose or normal saline to obtain a concentration of 10 mg/ml

• For deep intramuscular injection: add 2 ml of 5% dextrose or normal saline to obtain a concentration of 20 mg/ml

Table 1: Dilution of Artesunate for injection

Table 2: Dosage schedule for Artesunate injection

Half the dose is rounded up to 1ml; *Full vial (s) might not be required for a given weight band. The left–over solution must be discarded within 1hr of preparation and must not be reused

If the patient can tolerate oral medication after 24 hours provide a full treatment course of AL. Initiate the first dose of AL 8 hours after the last injection.

Alternative

Injectable Artemether

Injectable Artemether is to be used when Artesunate is contraindicated (in case of allergy, medicine interaction or non- response) and when not available. Artemether should be administered in a dose of 3.2mg/kg loading dose IM stat (0hour) then 1.6mg/kg (24hours and 48hours).

Table 3: Artemether injectable dosage by weight

If the patient can tolerate oral medication after 24 hours provide a full treatment course of ALu. Initiate the first dose of ALu 8hours after the last injection.