PenatalaksananPenatalaksanan intensifintensif pasienpasien dengandenganPenyakitPenyakit TropikTropik BeratBerat

didi ICUICU

Dr .Dr .DadikDadik WahyuWahyu WijayaWijaya SpAnSpAn

DepartemenDepartemen AnestesiologiAnestesiologi & & ReanimasiReanimasi / / InstalasiInstalasiPelayananPelayanan IntensifIntensif (ICU) (ICU)

FKFK--USU / RSUP USU / RSUP H.AdamH.Adam MalikMalik -- MedanMedan

11

IndikasiIndikasi UmumUmum PasienPasien dirawatdirawat didi ICUICU

�� BerdasarkanBerdasarkan PrioritasPrioritas

�� BerdasarkanBerdasarkan DiagnosisDiagnosis

�� BerdasarkanBerdasarkan NilaiNilai--nilainilai Parameter Parameter

HasilHasil LaboratoriumLaboratorium

22

PenyakitPenyakit TropikTropik BeratBerat (yang (yang seringsering

didi ICU :ICU :

�� Tetanus Tetanus BeratBerat (Severe Tetanus)(Severe Tetanus)�� Tetanus Tetanus BeratBerat (Severe Tetanus)(Severe Tetanus)

�� DHF Grade IIIDHF Grade III--IV (DSS)IV (DSS)

�� Malaria Malaria BeratBerat (Severe Malaria)(Severe Malaria)

33

TETANUS BERATTETANUS BERATTETANUS BERATTETANUS BERAT

44

DerajatDerajat KeparahanKeparahan

(Severity Grading(Severity Grading))

�� PhilipsPhilips

�� DakarDakar�� DakarDakar

�� UdwadiaUdwadia GambaranGambaran KlinisKlinis

�� AblettAblett

�� BlectBlect

55

Philips ScorePhilips ScoreWaktu Masuk Skor Selama Perawatan Skor

Masa Inkubasi

> 14 hari

> 10 hari

5 – 10 hari

2 – 5 hari

< 48 jam

1

2

3

4

5

Spasme

Hanya trismus

Kaku seluruh badan

Kejang terbatas

Kejang seluruh badan

Optistotonus

1

2

3

4

5

Imunisasi

Lengkap

< 10 tahun

> 10 tahun

Ibu diimunisasi

Tidak diimunisasi

0

2

4

8

10

Frekuensi Spasme

6 x dalam 12 jam

Dengan rangsangan

Terkadang spontan

Spontan < 3x per 15 menit

Spontan > 3x per 15 menit

1

2

3

4

5

Luka Infeksi Suhu Luka Infeksi

Tidak diketahui

Distal/perifer

Proksimal

Kepala

Badan

1

2

3

4

5

Suhu

36.7 - 37 C

37.1 – 37.7 C

37.8 – 38.2 C

38.3 – 38.8 C

> 38.8 C

1

2

4

8

10

Komplikasi

Tidak ada

Ringan

Tidak membahayakan

Mengancam Nyawa (tidak langsung)

Mengancam nyawa

1

2

4

8

10

Pernafasan

Sedikit berubah

Apnea saat kejang

Kadang apnea setelah kejang

Selalu apnea setelah kejang

Perlu trakeostomi

0

2

4

8

10

Total Skor Derajat Keparahan

< 9 Ringan

9 - 18 Sedang

>18 Berat 66

Grade I (mild)Mild trismus, general spasticity, no respiratory compromise, nospasms, no dysphagia

Grade 2 (moderate)

Ablett Classification of Severity

Grade 2 (moderate)Moderate trismus, rigidity, short spasms, mild dysphagia, moderate respiratory involvement, ventilatory frequency > 30

Grade 3 (severe)Severe trismus, generalized rigidity, prolonged spasms, severe dysphagia, apnoeic spells, pulse > 120, ventilatory frequency > 40

Grade 4 (very severe)Grade 3 with severe autonomic instability

77

�� DerajatDerajat KeparahanKeparahan hendaknyahendaknya tidaktidakdipakaidipakai sebagaisebagai pedomanpedoman ““KakuKaku”” untukuntukindikasiindikasi rawatrawat ICUICU

�� IndikasiIndikasi RawatRawat ICU ICU bilamanabilamana caracara--caracarakonvensionalkonvensional yang yang dilakukandilakukan didi ruangruangkonvensionalkonvensional yang yang dilakukandilakukan didi ruangruangperawatanperawatan tidaktidak berhasilberhasil mengatasimengatasi kejangkejang//spasmespasme atauatau pasienpasien mengalamimengalamigangguangangguan pernafasanpernafasan akibatakibat kejangkejang atauatauaspirasiaspirasi, , atauatau telahtelah terjaditerjadi gagalgagal nafasnafasatauatau gangguangangguan sistemsistem lain yang lain yang memerlukanmemerlukan terapiterapi supportifsupportif..

88

Clinical diagnosis of tetanus

Secure Airway

Tracheostomy

Benzodiazepines2

MidazolamDiazepam

Antitoxin2

HIG im/itEquine antitoxin im

Antibiotics2

MetronidazoleManage autonomic dysfunction

Flow diagram showing the management of tetanus.

1—limited evidence; 2—some evidence; 3—good evidence.

Magnesium2

Inotropes1

Benzodiazepines2

Bupivacaine2

Morphine2

Clonidine2

ConsiderDVT Prophylaxis1

Control Muscle Spasms

Benzodiazepines2 Dantrolene1

NDNMBA’s1 Baclofen2

Magnesium2

Full primary course of immunisation1

99

Therapeutic ManagementTherapeutic Management

ImmunizationImmunization

Wound debridementWound debridement

AntibioticsAntibioticsAntibioticsAntibiotics

Control muscle spasmControl muscle spasm

Control Autonomic DisturbanceControl Autonomic Disturbance

Other supportive therapyOther supportive therapy

1010

MANAGEMENTMANAGEMENT

1. 1. Neutralize toxin outside of CNSNeutralize toxin outside of CNS

-- Human Tetanus Immune Globulin Human Tetanus Immune Globulin

HTIGHTIG)) 150 units/kg IM or 5,000150 units/kg IM or 5,000--HTIGHTIG)) 150 units/kg IM or 5,000150 units/kg IM or 5,000--

10,000 units IV10,000 units IV

-- ATS ATS 500 UI/kgBB intramuscular.500 UI/kgBB intramuscular.

1111

22. . Prevent further toxin releasePrevent further toxin release

-- Early surgical debridement of Early surgical debridement of

woundswounds

-- Antibiotics : Antibiotics : MetronidazoleMetronidazole 500mg500mg

MANAGEMENTMANAGEMENT

-- Antibiotics : Antibiotics : MetronidazoleMetronidazole 500mg500mg

8 hourly and Penicillin G 1 MU 68 hourly and Penicillin G 1 MU 6--88

hourly. hourly.

Heavily contaminated wound mayHeavily contaminated wound may

need additional antibiotics.need additional antibiotics.1212

MANAGEMENTMANAGEMENT

3.3. Minimize the effects of toxin already Minimize the effects of toxin already

exists in CNSexists in CNS

-- Control rigidity and spasmControl rigidity and spasm-- Control rigidity and spasmControl rigidity and spasm

-- Respiratory support as necessary Respiratory support as necessary

-- Control of autonomic dysfunction.Control of autonomic dysfunction.

1313

Drug used to control spasm and Drug used to control spasm and autonomic disturbanceautonomic disturbance

BenzodiazepineBenzodiazepine

MorphineMorphine

Muscle relaxant: Muscle relaxant: vecuroniumvecuronium, , rocuroniumrocuronium, , Muscle relaxant: Muscle relaxant: vecuroniumvecuronium, , rocuroniumrocuronium, , pancuroniumpancuronium

Magnesium sulfateMagnesium sulfate

DantrolenDantrolen

BaclofenBaclofen

BupivacainBupivacain, atropine,, atropine,1414

BenzodiazepineBenzodiazepine

Common used as anticonvulsant in Common used as anticonvulsant in tetanus.tetanus.

Has sedative effectHas sedative effect

Dose of Diazepam vary 100Dose of Diazepam vary 100--400 mg/24 h 400 mg/24 h Dose of Diazepam vary 100Dose of Diazepam vary 100--400 mg/24 h 400 mg/24 h max until 2400mg/24 hmax until 2400mg/24 h

Preservative used can cause acidosis in Preservative used can cause acidosis in large doselarge dose

No/little effect on autonomic disturbanceNo/little effect on autonomic disturbance

1515

Magnesium SulfateMagnesium Sulfate

-- Pre synaptic neuromuscular blockerPre synaptic neuromuscular blocker

-- Blocks catecholamine release from nerve and Blocks catecholamine release from nerve and

adrenal medullaadrenal medulla

-- Reduce receptor responsiveness to release Reduce receptor responsiveness to release

catecholaminescatecholamines

-- It antagonizes calcium in myocardium and at It antagonizes calcium in myocardium and at

the neuromuscular junctionthe neuromuscular junction

-- Inhibits parathyroid hormone releaseInhibits parathyroid hormone release

anticonvulsant-vasodilator1616

DoseDose

Adult : a loading dose of 5 gram over 20 Adult : a loading dose of 5 gram over 20 minutes IV followed by 1g hourly minutes IV followed by 1g hourly increasing to 2.5 gram hourly when increasing to 2.5 gram hourly when necessary. Titrate to symptomsnecessary. Titrate to symptomsnecessary. Titrate to symptomsnecessary. Titrate to symptoms

Pediatrics : 100mg /kg/24 hours, can be Pediatrics : 100mg /kg/24 hours, can be increased when necessary. Titrate to increased when necessary. Titrate to symptomssymptoms

Sometimes MgSO4 is inadequate to be used alone, combination with benzodiazepine is also mandatory

1717

Monitoring of possible side effectsMonitoring of possible side effects

-- Patellar reflexPatellar reflexDiminished at the level of Magnesium >4 Diminished at the level of Magnesium >4 mmolmmol/L/L

-- Respiratory depression because of muscle Respiratory depression because of muscle paralysis (>Mg 6 paralysis (>Mg 6 mmolmmol/L)/L)

-- BradyarrhythmiaBradyarrhythmia, hypotension, hypotension-- BradyarrhythmiaBradyarrhythmia, hypotension, hypotension-- Urine output Urine output

Low output causes drug accumulationLow output causes drug accumulation-- Blood Calcium level, blood Magnesium level Blood Calcium level, blood Magnesium level

should be checked regularlyshould be checked regularly-- Overdose may cause sedation and anesthesia.Overdose may cause sedation and anesthesia.

Day 4 Day 6

Magnesium can be a prospective

alternative for treatment of tetanus,

especially when there are mass

casualties since it reduces the need for casualties since it reduces the need for

mechanical ventilation, however,

meticulous ICU monitoring is needed

with ready for use ventilator.

Gempa Yogyakarta

Others Drugs & RegimentOthers Drugs & Regiment

ObatObat pelemaspelemas otototot (muscle relaxant) (muscle relaxant) intermittent intermittent bilabila diperlukandiperlukan. .

BaclofenBaclofen (beta (beta –– [4[4--chlorophenyl] gamma chlorophenyl] gamma amino butyric acid) amino butyric acid) sebagaisebagai PP--GABA GABA amino butyric acid) amino butyric acid) sebagaisebagai PP--GABA GABA receptor agonist, receptor agonist, menghambatmenghambat pelepasanpelepasanasetilkolinasetilkolin presinapspresinaps diotakdiotak, , diberikandiberikanintrathekalintrathekal

PropofolPropofol (1,6(1,6--diisopropyl phenol) diisopropyl phenol) dapatdapatdipakaidipakai sebagaisebagai sedasisedasi, , dengandengan dosisdosistritrasitritrasi. .

2222

Others Drugs & RegimentOthers Drugs & Regiment

PenghambatPenghambat beta :beta :Propanolol,LabetololPropanolol,Labetolol, , EsmololEsmolol

Agonist alfaAgonist alfa--2 : 2 : ClonidineClonidine

DexmedetomidineDexmedetomidineDexmedetomidineDexmedetomidine

OpioidOpioid kombinasikombinasi dengandengan sedative :sedative :Morphine + Morphine + midazolammidazolam atauatau diazepam diazepam

Sodium Sodium valproatevalproate

ACE Inhibitor ACE Inhibitor 2323

TerapiTerapi supportifsupportif lainnyalainnya

�� Terapi fisik (fisioterapi) karena pasien Terapi fisik (fisioterapi) karena pasien imobilisasi cukup lama. imobilisasi cukup lama.

�� VentilasiVentilasi mekanikmekanik

MANAGEMENTMANAGEMENT

�� VentilasiVentilasi mekanikmekanik

�� Metabolik : Nutrisi enteral , ditambah Metabolik : Nutrisi enteral , ditambah parenteral bila perlu.parenteral bila perlu.

�� Penggunaan inotropik dan atau Penggunaan inotropik dan atau vasopresorvasopresor

�� AntikoagulanAntikoagulan2424

3 major complications cause death3 major complications cause death

VentilatoryVentilatory restriction leading to respiratory restriction leading to respiratory VentilatoryVentilatory restriction leading to respiratory restriction leading to respiratory complication and sepsiscomplication and sepsis

Autonomic disturbanceAutonomic disturbance

Stress ulcer/gastric bleedingStress ulcer/gastric bleeding

2525

DHF GR IIIDHF GR III--IV (DSS)IV (DSS)DHF GR IIIDHF GR III--IV (DSS)IV (DSS)

2626

DF DHF (Grades)

I II III IV

FebrilePhase(3-7 days)

Afebrile Phase(Critical Stage)(Critical Stage)

ConvalescentPhase

If Appropriate Treatment not provided, there is a high rist death

RECOVERY

Grading the Severity of Dengue Infection

DF/DHF Grade* Symptoms Laboratory

DF

DHF

DHF

I

II

Fever with two or more of the following signs : headache, retro –orbital pain, myalgia, arthalgia

Above signs plus positive Tourniquet test

Above signs plus spontaneous

Leukopenia, Occasionally, Thrombocytopenia, may be present, no evidence of plasma loss

Thrombocytopenia, < 100,000, Hct rise ≥ 20 %

Thrombocytopenia, < 100,000, DHF

DHF

DHF

II

III

IV

Above signs plus spontaneous bleeding

Above signs plus circulatory failure (weak pulse, hypotension,restlessness)

Profound shock with undetectable blood presure and pulse

Thrombocytopenia, < 100,000, Hct rise ≥ 20 %

Thrombocytopenia, < 100,000, Hct rise ≥ 20 %

Thrombocytopenia, < 100,000, Hct rise ≥ 20 %

* DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS)

Clinical Manifestation DSSClinical Manifestation DSS

Increase of Vascular permeability : Increase of Vascular permeability : HaemoconcentrationHaemoconcentration, , HypoalbuminemiHypoalbuminemi, , HypoproteinemiaHypoproteinemia, Shock, Pleural , Shock, Pleural effusioneffusioneffusioneffusion

ThrombopathyThrombopathy

CoagulopathyCoagulopathyHemorrhage

2929

PENATALAKSANAAN

Afebrile phase

Duration two daysafter febrile stage

Manifestations

In addition to the manifestations ofDHF Grade II :– Circulatory failurse manifested by

rapid and weak pulse, narrowingof pulse pressure (20 mmHg orless) or Hypotension with thepresence of cold clammy skinand restlessness

– Capillary relief time more thantwo seconds

Management

– Check haematocrits/platelet

– Initiate IV Therapy (5% D/NSS) 10 ml/kg/h– Check Haematocrit , vital signs, urine output every

hour.– If patient improves IV fluids should be reduced every

hour from 10 to 6 and from 6 to 3 ml/kg/h which can bemaintained up to 24 to 48 hours.

– If patients has already received one hour treatment of20 ml/kg/hr of IV fluids and vital signs are not stablecheck haematocrit again andtwo seconds

Profound shock with undetectablepulse and blood pressure.

check haematocrit again and– If haematocrit is increasing change IV fluid to colloidal

solution preferably Dextran or plasma at 10 ml/kg/hevery hr.

– If haematocrit is increasing from initial value give freshwhole blood transfusion, 10 ml/kg/h and continue fluidtherapy at 10 ml/kg/h and reducing it stepwise bringdown the volume to 3 ml/kg/h and maintain it up to 24 –48 hours.

– Initial IV therapy (5% D/NSS) 20 ml/kg as a bolus oneor two times

– Oxygen therapy should be given to all patients.– In case of continued shock colloidal fluids (Dextran or

Plasma) should be given at 10 – 20 ml/kg/hr.

Afebrile phase

Con Phase

Manifestation

Profound shock with undetectablePulse and blood pressure

Manifestation

Management

- If shock still persists and the haemotocrit level continues declining give fresh whole blood 10 ml/kg as a bolus

- Vital signs should be monitored every 30 –60 minutes

- In case of severe bleeding gives fresh whole blood 20 ml/kg as a bolus

- Give platelet rich plasma transfusion exceptionally when platelet counts are below 5.000 – 10.000 / mm3

- After blood transfusioncontinues fluid therapy at 10 ml/kg/h and reduce it stepwise to bring it down to 3 ml/kg/h and maintain in for 24 – 48 hrs

ManagementCon Phase

Duration 2 – 3 daysAfter recovery from critical/shock stage

Manifestation

- 6 – 12 hours after critical/shock stage some symptoms of respiratory distress (pleural effusion or arcites)

- 2-3 days after critical stage , strong pulse, normal blood pressure.

- Improved general condition/return of appetite.

- Good urine output- Stable haematocrit- Pletelet count > 50.000 per mm3

- Patient could bedischarged from hospital 2 – 3 days after critical stage

- Bradycardia/arrhytmia- Asthenia and depression (few

weeks) in adult

Management

- Rest for 1 – 2 days- Normal diet- No need for medication

Fluid Therapy in DSSFluid Therapy in DSS

The policy of initial fluid therapy in DSS The policy of initial fluid therapy in DSS

according to the according to the Department of Health Department of Health

and WHO until 2003 :and WHO until 2003 :

Crystalloid (Lactate Ringer), followed Crystalloid (Lactate Ringer), followed

with colloid (with colloid (DextranDextran) if not responded) if not responded

3232

Department of HealthDepartment of HealthIndonesian Intensive Care AssociationIndonesian Intensive Care Association

Indonesian Anesthesiology AssIndonesian Anesthesiology AssIndonesian Indonesian PaedPaed. Ass (2004). Ass (2004)

Review on the management of DHFReview on the management of DHFReview on the management of DHFReview on the management of DHF

Change the protocolChange the protocol

Include colloid MMWInclude colloid MMW--6% HES as alternative as 6% HES as alternative as

initial fluid resuscitation in DSSinitial fluid resuscitation in DSS

3333

Lactated Ringer's

Volume Replacement Therapy Volume Replacement Therapy

ColloidsCrystalloidsCrystalloids

HES

solutions

Dextran

solutions

Gelatin

solutionsAlbuminPPL

Lactated Ringer's

Normal Saline

3434

Crystalloid (RL, RA, Crystalloid (RL, RA, NaCLNaCL))

Distributed to the interstitial spaceDistributed to the interstitial space

Very short period in the intravascular spaceVery short period in the intravascular spaceVery short period in the intravascular spaceVery short period in the intravascular space

Need more fluid to maintain intravascular Need more fluid to maintain intravascular

volume volume �������� risk for interstitial edema / risk for interstitial edema /

pulmonary edemapulmonary edema

3535

–– HES: ( MW 100.000HES: ( MW 100.000--300.000 300.000 kDkD ): Sealing ): Sealing

effect +, effect +, good intravascular volume effect, good intravascular volume effect,

longer duration in the intravascular space, longer duration in the intravascular space, ↑↑↑↑↑↑↑↑

ColloidColloid

DO2, DO2, ↑↑↑↑↑↑↑↑VO2VO2

–– DextranDextran : : LMW colloid (40.000LMW colloid (40.000--70.000 70.000 kDkD))

with good preservation volume effect, with good preservation volume effect, no no

sealing effectsealing effect, increase anaphylactic , increase anaphylactic

reactionreaction

3636

HydroxyethylHydroxyethyl Starch (HES)Starch (HES)

-- Effective Effective and safe plasma substituteand safe plasma substitute

-- HES HES �������� broad range of MW, from very small until broad range of MW, from very small until

several hundred thousand Daltonseveral hundred thousand Dalton

-- Classification of HES (by in vitro) according to Classification of HES (by in vitro) according to -- Classification of HES (by in vitro) according to Classification of HES (by in vitro) according to MW:MW:-- HIGH MOLECULAR WEIGHT (HMW) HIGH MOLECULAR WEIGHT (HMW) →→ 450 K 450 K DaDa

-- MEDIUM MOLECULAR WEIGHT (MMW) MEDIUM MOLECULAR WEIGHT (MMW) →→ 200 K 200 K DaDa

-- LOW MOLECULAR WEIGHT (LMW) LOW MOLECULAR WEIGHT (LMW) →→ 70 K 70 K DaDa

Sealing effectSealing effect : HES with 100: HES with 100––300.000 D MW300.000 D MW

Effect Effect of HES on Blood Coagulationof HES on Blood Coagulation

HMWHMW--HES HES ��������more effect on blood coagulation more effect on blood coagulation

((vWFvWF, factor VIII), factor VIII)

LMW (HES 70/0.5/4)/LMW (HES 70/0.5/4)/MMW(HES 200/0.5/6MMW(HES 200/0.5/6) ) �������� did did LMW (HES 70/0.5/4)/LMW (HES 70/0.5/4)/MMW(HES 200/0.5/6MMW(HES 200/0.5/6) ) �������� did did

not affect on blood coagulationnot affect on blood coagulation

Possible Possible dilutionaldilutional coagulation effect : PT, coagulation effect : PT, aPTTaPTT

(significant prolongation after HMW(significant prolongation after HMW--HES 480)HES 480)

Fluid Resuscitation in DSSFluid Resuscitation in DSS

Primary importance in the management Primary importance in the management

of of hypoperfusionhypoperfusion statestate

Goal of therapyGoal of therapyGoal of therapyGoal of therapy

↑↑ Tissue DOTissue DO22

↑↑ Blood PressureBlood Pressure

↑↑ VOVO22

Reversing Lactic AcidosisReversing Lactic Acidosis

Colloid Colloid MMW MMW

3939

Study on DSS using colloid (HES ) Study on DSS using colloid (HES ) as initial fluid resuscitationas initial fluid resuscitation

Tatty E. Tatty E. SetiatiSetiati Different

RESULTTatty E. Tatty E. SetiatiSetiati

(2000)(2000)

HerminiaHerminia L. L. CifraCifra

(2001(2001) H) H

RESULT

Different

method of

study

4040

RL group Colloid group (HAES Steril 6%)

Duration of

shock ( Hour)

7.9+/- 2.6 2.3 +/- 2

Ventilators days 8 +/- 1.1 4.0 +/- 0.71

Pleural effusion 30M2/Mod7/S21

_

ALI /PaO2/FiO2=200-250 4 1

ARDSPaO2/FiO2 < 200

6 2

ConclusionConclusion

Evidenced showed that endothelial dysfunction Evidenced showed that endothelial dysfunction

lead to vascular leakage and lead to vascular leakage and hemostatichemostatic

disturbances occurred in DSSdisturbances occurred in DSS

MMW which has a sealing effect could MMW which has a sealing effect could MMW which has a sealing effect could MMW which has a sealing effect could

minimizing vascular leakage, good preservation minimizing vascular leakage, good preservation

volume effect, and lowering mortalityvolume effect, and lowering mortality

MMW HES can be used as alternative for initial MMW HES can be used as alternative for initial

fluid resuscitation in DSSfluid resuscitation in DSSS S

4242

What not to do in DSS

Do not give Aspirin or Ibuprofen for treatment of fever.

Avoid giving intravenous therapy before there is evidence of haemorrhage and bleeding.

Avoid giving blood transfusion unless indicated, reduction in haematocrit or severe bleeding.in haematocrit or severe bleeding.

Avoid giving steroids. They do not show any benefit.

Do not use antibiotics

Do not change the speed of fluid rapidly, i.e. avoid rapidly increasing or rapidly slowing the speed of fluids.

Insertion of nasogastric tube to determine concealed

bleeding or to stop bleeding (by cold lavage) is not

recommended since it is hazardous.

4343

Signs of Recovery

Stable pulse, blood pressure and breathing rate

Normal temperature

No evidence of external or internal bleeding

Return of appetiteReturn of appetite

No vomiting

Good urinary output

Stable haematocrit

Convalescent confluent petechiae rash

4444

SEVERE MALARIASEVERE MALARIASEVERE MALARIASEVERE MALARIA

4545

What is severe malaria?

Severe malaria is the serious or life-threatening

form of falciparum malaria which needs active

appropriate patient management.

According to WHO criteria in 1990, severe malaria

patients have asexual forms of Plasmodium

falciparum on a blood film and may have any one

or more of the following manifestations and

complications :

4646

1. Cerebral malaria (unrousable coma not

attributable to any other cause)

2. Severe normocytic anemia (haematocrit <15% or hemoglobin <5 g/dl)

3. Acute renal failure (urine output <400 ml/24 3. Acute renal failure (urine output <400 ml/24 hours in adults or 12 ml/kg/24 hours in children, failing to improve after redydration and

serum creatinine >265 mmol/l (3 mg/dl))

4. Pulmonary edema or adult respiratory distress syndrome (ARDS)

4747

5. Hypoglyceamia (whole blood glucose <2.2

mmol or l40 mg/dl)

6. Circulatory collapse, shock: hypotension

(systolic blood pressure <50mmHg in children

aged 1-5 years or <70 mmHg in adults), with

cold clammy skin or core-skin temperature

difference >10 °C)

7. Spontaneous bleeding/disseminated

intravascular coagulation (DIC)

8. Repeated generalized convulsions

9. Acidaemia (arterial pH <7.25) or acidosis

(plasma bicarbonate <15 mmol/l)

10. Macroscopic haemoglobinuria

11. Post-mortem confirmation of diagnosis4848

WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 –– 2000)2000)

PREVALENCE OF SIGNS AND SYMPTOMSPREVALENCE OF SIGNS AND SYMPTOMS

SIGNS AND SYMPOMS NUMBER %

SEVERE ANEMIA 666 54.1SEVERE ANEMIA 666 54.1

PROSTRATION 371 30.2

CONVULSIONS 279 22.7

CEREBRAL MALARIA 218 17.7

HYPOGLYCEMIA 162 13.2

HYPOGLOBINURIA 41 3.3

JAUNDICE 21 1.7

RESPIRATORY DISTRESS 12 1.0

DISSEMINATED INTRAVASCULAR 1 0.08

COAGULATION

4949

Different clinical manifestation between adults and children with severe malaria

Adult Children

Cough Uncommon early symptom Common early symptom

Convulsions Indicate cerebral involvement May indicate cerebral

involvement or hypoglycemia,

but may be non – specific

consequence of fever

Duration of symptoms Commonly several days Usually 1 – 2 days onlybefore features of severebefore features of severedisease develop

Jaundice Common Uncommon

Time from start of Usually quinine 2 – 4 days Usually 1 – 2 daystreatment to resolutionof coma in cerebral malaria

Hypoglycemia Relatively uncommon CommonUsually quinine-induced (especially in pregnancy)

Pulmonary edema Common RareRenal failure Common RareNeurological sequelae Uncommon Occur in about 10% of cases

after cerebral malaria

ManagementManagement

· Parenteral antimalarials.

· IV fluid administration.

· Vital signs monitoring every 4 hours.

· Blood check up for malaria parasite every day until disappearance of parasitemia.day until disappearance of parasitemia.

· Monitoring clinical signs and symptoms of severe malaria that may occur later.

· Record conscious level every 4 hours and urine output every 8 hours.

5151

Antimalarial drug doses in severe malariaHospital

ICU

Health Clinic :

No Intravenous

Infusion Possible

Rural health clinic :

No injection facilities

Chloroquine-resistant

P falcipanum

Quinine

Quinine dihydrochloride

7 mg salt/kg infused over

30 min followed by

Immediately 10 mg/kg

Over 4 h: or 20 mg salt/kg

Infused over 4 h

Maintenance dose: 10 mg

Salt/kg infused over 2-8 h

Quinine dihydrochloride

20 mg salt/kg diluted 1 : 2 with sterile

water given by split injection into both

anterior thighs. Maintenance dose : 10

mg/kg 8 hourly

Artesunate rectocap :

10 mg/kg daily

Artemisinin suppository

20 mg/kg at 0 and 4 h

Then daily

Chloroquine – sensitive

P falcipanum

Salt/kg infused over 2-8 h

At 8 h intervals

Arteminisim derivative :

a) Artemether 3.2 mg/kg

Stat By im injection

Followed by 1.6 mg/kg

Daily

a) Artesunate 2.4 mg/kg stat

By iv injection followed by 1.2

mg/kg daily

Chloroquine

Chloroquine 10 mg base/kg

Infused iv at constant rate over 8 hr

followed by 15 mg base/kg over 24 hr

As for Hospital ICU :

Artesunate can also be

Given by im injection

Chloroquine 3.5 mg

Base kg 6-hourly or 2.5 mg

base/kg 4 hourly by im or sc injection.

Total dose 25 mg base/kg

Chloroquine 10 mg/kg daily

Or nasogastric chloroquine as for

oral regimen

Poor prognostic features in severe malaria

Clinical findings

� Deep Coma� Deep Coma

� Repeated convulsions

� Respiratory distress (rapid, deep, laboured, stertorous,

breathing often with intercostals recession)

� Significant bleeding

Laboratory findings

Biochemistry

� Hypoglycemia < 2.2 mmol/l� Hyperlactatemia > 5 mmol/l� Acidosis arterial pH<7.3 venous plasma HCO3 < 15 mmol/l� Serum creatitine >265 µmol/l� Total bilirubin > 50 µmol/l� Liver enzymes SGOT (AST) x 3 upper limit of normal

SGPT (ALT) x 3 upper limit of normal5 – Nucleotidase

� Muscle enzymes CPKMyoglobin

� Urate > 600 µmol/l� Urate > 600 µmol/l

Hematology

� Leucocytosis >12.999/µl� Severe anemia PCV < 15 %� Coagulopathy Platelet < 50.000/µl

PT prolonged > 3 sProlonged PPTFibrinogen <200 mg/dl

Parasitology

� Hyperparasitemia > 100.000/µl - increased mortality> 500.00/µl - high mortality

� >20% of parasites are pigment – containing trophozoites and schizonts� >5% of neutrophils contain visible malaria pigment

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