Malaria Other Complications

8/8/2019 Malaria Other Complications

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Managementof

Other malarialcomplications


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Supportive and ancillary treatmentResuscitation


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Laboratory support


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Nursing care


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Severe anemia

Severe anemia: Hb


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Blood transfusion for severe anemia


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Abnormal bleeding and DIC Symptomatic bleeding amy be due to

thrombocytopenia or DIC.

Asymptomatic thrombocytopenia is very commonin falciparum malaria.

Transf use fresh blood, clotting factors, or plateletconcentrates in systemic bleeding or DIC.

Platelet transfusion is not recommended inasymptomatic thrombocytopenia or ecchymosis ofskin or subconjunctival or retinal hemorrhage.


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Hyperparsitemia

Definition There is not enough evidence to provide a

firm recommendation on the definition of

hyperparsitemia.

5% parasitemia in low-transmission

setting

10% in higher-transmission setting


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Hyperparsitemia

TreatmentHyperparasitemic patients with no other signs ofsevere disease should be treated with oral

artemisinin derivativesu

nder the followingconditions:

Patients must be monitored closely for the first 48h after the start of treatment

If the patient does not retain on oral medication,parenteral treatment should be given withoutdelay.

Non-immune patients with parasitemia of > 20%

should receive parenteral treatment.


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Exchange blood transfusion

Rationale Removing infected RBC from circulation ->

lower parasite burden

Reducing rapidly antigen load and parasite-derived toxins, metabolites and toxinmediators produced by the host

Replacing the rigidunparasitized R

BC bymore deformable cells-> alleviating

microcirculatory obstruction


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WHO indication in 2000 Parasitemia >30% without severe disease

Parasitemia>10% with severe disease

Parasitemia >10% and failure to respond to

optimal chemotherapy after 12-24 h

Parasitemia >10% and poor prognostic

factors (eg elderly patients, shizonts)


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WHO indication in 2006 No consensus on indications, benefits and

dangers involved, or on practical details eg.

volume of blood forEBT.

No recommendation regarding the use of

EBT


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Hypoglycemia

Pathogensesis Increased peripheral requirement for glucose

consequent upon anarobic glycolysis

Increased metabolic demands of the febrile illness

obligatory demands of the parasites which use

glucose as their fuel

failu

re of hepatic glu

coneogenesis andglycogenolysis

Quinine-induced hyperinsulinemia


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Hypoglycemia

Management In all suspected cases, 50 glucose 50 ml

should be given and followed by an IV

infusion of 5% or 10% dextrose.

Blood glucose level should be monitored to

regulate the dextrose infusion.


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Treatment of hypoglycemia


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Treatment of convulsions


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Shock/circ

ulatory collapse

Correct hypovolemia with appropriate fluid

Look for possible sites of infection

Take blood culture and start broad-spectrum

antibiotics, eg 3rd generation

cephalosporins

If patients do not respond to adequate fluid

therapy, ionotropic agents are helpful.


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Fluids


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Concomitant use of antibiotics in

severe malaria Threshold for administering antibiotic treatment

should be low in severe malaria.

Septicemia and severe malaria are associated andthere is diagnostic overlap, particularly inchildren.

Enteric bacteria (notably Salmonella) have

predominated in most trial series, a variety ofbacteria have been cultured from blood of severemalaria patients. Broad-spectrum antibiotic shouldbe given initially.


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Broad-spectrum IV antibiotics

Severely ill or shocked patients

Unconscious patients


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Metabolic acidosis

Pathogenesis Severe dehydration is the most important

contributor

Blood lactate levels rises due to tissue

hypoxia, increased body metabolism, and

failure of hepatic clearance of lactate -> loss

of bicarbonate ->metabolic acidosis


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Metabolic acidosis

Clinical features Hyperventilation

Kussmauls breathing

Chest signs are usually absent.

Presence of chest signs (crepitations and/orrhonchi) is indicative of pulmonary

edema/ARDS or associated pneumonia. Arterial pH and plasma bicarbonate will

confirm the diagnosis.


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Jaundice

Pathogensis: Hemolysis and hepatic dysfunction

Liver failure with hepatic encephalopathy is rare.

Jaundice is considered as severe malaria in WHO 1990 and

2006 criteria as it may be associated with vital organdysfunction.

Jaundice with vital organ dysfunction indicates severe

disease. In WHO 2000 criteria, jaundiceper se without

vital sign dysfunction is not considered severe malaria.

Jaundice is more common in adults than in children.

No specific treatment.


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Blackwater fever

Uncommon

Causes: - massive hemolysis in normal G6PD

- hemolysis in G6PD deficiency Mortality is high when it is associated with severe

malaria and other vital organ dysfunction.

Not associated with significant renal impairment

Usually transient and resolves withoutcomplications; in severe cases renal failure maydevelop.


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F

ever Paracetamol 15 mg/kg 4-hourly, may be

given PO or PR.

Tepid sponging and fanning to try to keep

the rectal temperature < 39 C; May ask

relatives to do this.

NSAID is not recommended and may causeGI bleeding.


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Unproved or harmful adjuvants Heparin

Prostacyclin

Desferoxamine

Pentoxifylline

Low molecular weight dextran

Urea

Corticosteroids

Acetylsalicylic acid

Anti-tumor necrosis factor Ab

Cyclosporin Dichloroacetate

Adrenaline

Hyperimmune serum


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Severe anemia

Give blood transfusion in


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Documents

Malaria Other Complications