Clinical management of Malaria in Uganda

Severe Malaria — Defining Manifestations

Cerebral malaria: deep coma with parasitaemia. Severe anaemia: Hb <5 g/dl with parasitaemia. Respiratory distress: tachypnoea, nasal flaring, intercostal recession. Hypoglycaemia: blood glucose <2.2 mmol/L (<40 mg/dl). Circulatory collapse: systolic BP <80 mmHg (adult), <50 mmHg (child). Renal failure: urine <12 ml/kg/24h, creatinine >3.0 mg/dl. Spontaneous bleeding. Repeated convulsions: ≥2 in 24 hours.

Severe Malaria — Supporting Manifestations

Acidosis: plasma bicarbonate <15 mmol/L. Haemoglobinuria (dark urine, no RBCs). Pulmonary oedema. Impaired consciousness (not deep coma). Jaundice. Prostration. Severe vomiting. Severe dehydration. Hyperpyrexia: temperature >39.5°C. Hyperparasitaemia: >250,000/µl or >10%. Threatening abortion in pregnancy.

General Principles

Medical emergency — manage complications as listed below. Manage fluids carefully: adults are vulnerable to fluid overload; children more likely dehydrated. Monitor vital signs and urine output carefully.

Pre-referral Treatment (children ≤6 years, no IV available)

Rectal artesunate: 5–<14 kg (4mo–3yr): 100 mg (1 suppository). 14–19 kg (3–6 yr): 200 mg (2 suppositories of 100 mg). Hold buttocks together for 10 minutes to ensure retention. If expelled within 30 minutes, re-insert.

First Line — IV Artesunate

IV Artesunate: child <20 kg: 3 mg/kg. Adults and child ≥20 kg: 2.4 mg/kg. Give at 0 hours (loading), 12 hours, 24 hours, then once daily. Reconstitute with bicarbonate ampoule (1 ml) in powder vial. Dilute with 5 ml NS or D5% for IV (10 mg/ml), or 2 ml NS for IM (20 mg/ml). Give IV slowly over 5 minutes. IM: inject in upper outer anterior thigh — NEVER in buttock. Continue until patient tolerates oral medications; then complete full course of oral ACT. Discharge on Dihydroartemisinin/Piperaquine for post-severe malaria chemoprevention (monthly for 3 months).

First Line Alternative — IV Quinine

Quinine 10 mg/kg in Dextrose 5% every 8 hours until patient tolerates oral medication. Then complete with full course of ACT (3 days) or quinine tablets to complete 7 days.

Alternative — IM Artemether

As per IM dosing tables. Use upper outer anterior thigh. Never use gluteal site.

Complication: Hyperpyrexia

Paracetamol 1 g every 6 hours (child: 10 mg/kg) + tepid sponging and fanning.

Complication: Convulsions

Diazepam 0.2 mg/kg slow IV (max 10 mg) or rectally 0.5 mg/kg. If persistent: Phenobarbital 200 mg IM/IV (child: 10–15 mg/kg loading, then 2.5 mg/kg once or twice daily). Or Phenytoin 15 mg/kg loading dose.

Complication: Hypoglycaemia

Adult: Dextrose 25% 2 ml/kg slow IV over 3–5 min. Child: Dextrose 10% 5 ml/kg slow IV over 5–7 min. Then Dextrose 10% IV maintenance infusion.

Complication: Severe Anaemia

Blood group and crossmatch. Transfuse packed cells 10–15 ml/kg OR whole blood 20 ml/kg (especially if causing heart failure). Repeat Hb before discharge and at 28 days.

Complication: Pulmonary Oedema

Regulate IV infusion — do NOT overload with IV fluids. Prop up patient. Give oxygen. Furosemide 1–2 mg/kg.

Complication: Acute Renal Failure

Target urine output: adult >17 ml/hour; child >0.3 ml/kg/hour. Rule out dehydration/shock as cause of oliguria. If confirmed renal failure: Furosemide 40 mg IM/IV (child: 1 mg/kg). If no response: refer for peritoneal dialysis or haemodialysis.

Complication: Shock

If systolic BP <80 mmHg (adult) or <50 mmHg (child), or absent peripheral pulse with slow capillary refill: IV fluid bolus 10–20 ml/kg Normal Saline rapidly. Assess for bacterial co-infection and treat empirically.

Complication: Coma (Cerebral Malaria)

Position in recovery position. Maintain airway. NG tube for feeding and to prevent aspiration. Bladder catheter to monitor urine output. Anti-epileptic as above. Do NOT use corticosteroids (shown to be harmful). Monitor closely for hypoglycaemia.