MANAGEMENT OF SEVERE MALARIA

Mx ORGAN DYSFUNCTION

Paul N Harijanto
 MANAGEMENT SEVERE MALARIA

• SPECIFIC TREATMENT
– ANTI MALARIAL DRUGS ( ARTESUNATE )

• ORGAN FAILURE TREATMENT

• SUPPORTIVE TREATMENT

• ANCILLARY TREATMENT
 INITIAL ASSESMENT

 Asses Airway, Breathing, Circulation

 Weigh BW for calculate dose artesunate
 Insert i.v. line (Solution NaCl 0.9%, preferable)
 Clinical Exam : Vital sign, GCS, jaundice, hepato-
splenomegali, lungs
Measurement intake-output balance
 Lab : Bl. Sugar, Hb, WBC, ureum, creatinine,
serum bilirubin, SGOT/SGPT, Bl. Gas, lactate
 MANAGEMENT OF ORGAN FAILURE

 ENCEPHALOPATHY/
CONVULSION  ANTI – CONVULSAN
 RENAL FAILURE  DIALYSIS – EQUIPMENT
 ACIDOSIS  BL. GAS ANALYSER
 HYPOGLYCAEMIA  20% DEXTROSE
 HYPERBILIRUBINAEMIA  VIT –K,
 RESPIRATORY FAILURE  VENTILATOR
 HYPOTENSION  CIRCULATORYSUPPORT
 SEPSIS  ANTI-BIOTIC&SUPPORT
 SEVERE ANAEMIA  TRANSFUSSION
 Penanganan malaria serebral

• Tanda vital: TD, Nadi, Resp, Suhu Gula darah, Parasit

• Kesadaran : GCS
• Oksigenasi

• Pencegahan kejang : diazepam, luminal, largactil

• Mencegah trauma/ jatuh

• Mengatasi anxiety, delirium state

• Deteksi organ dysfunction

• Resiko infeksi bakterial

 Mx Coma & Seizures

• ABCD ( A=airway, B= breathing, C=circulation,

D=dehydration)
• Correct hypoxia, hypoglycaemia and metabolic
acidosis
• Not/ difficult breathing: insert Guedel airway  bag
& mask ventilation
• Insert a nasogastric tube to empty the stomach
• Turning unconscious child every 2 h, attention to
pressure spots and oral and eye care
 Glasgow Coma Scale

• Respon mata : spontan 4

dgn suara 3
dgn nyeri 2
tak ada reaksi 1
• Respon Bicara : normal respon 5
bingung 4
berkata kacau 3
suara merintih 2
tak ada suara 1
• Respon motorik : gerakan normal 6
dapat melokalisir nyeri 5
fleksi thdp nyeri 4
extensi 3
decerebrate rigidity 2
tak ada reaksi 1
TOTAL 3 -- 15
 Blantyre Coma Scale (modifikasi)
• Respon mata :
mengikuti wajah ibu 1
tak ada reaksi 0

• Respon Bicara :
menangis wajar 2
menangis merintih 1
tak ada suara 0

• Respon motorik :
melokalisir nyeri 2
menarik anggota o.k. nyeri 1
tak ada reaksi 0
TOTAL 0 --5
 Convulsions

• I.v. diazepam 10 mg –adult or rectal 0.5-1.0

mg/kg
• i.m paraldehyde o.1 mg/kg – adult
• Repeated conv- chlormethiazol infussion 0.8
%,
• Phenytoin 5 mg/kg i.v. 20 minutes
• Fosphenytoin 7.5 mg/kg i.v …20 mnutes
 ANCILLARY TREATMENTS
RECOMMENDATIONS

• Recommended ancillary treatments

– Acetaminophen for pyrexia
– Phenobarbital to prevent convulsions
– Exchange transfusion for hyperparasitaemia > 15%*

• Treatments to be avoided
– Antibody TNF, Dextran, Hyperimmunoglobulin, Allopurinol, Desferioxamine, Pentoxifylline, Heparin,
Mannitol, Prostacycline, Acetylcystein, Aspirin, Corticosteroid, Cyclosporine, Epinephrin ( Adrenalin), Di-
chloroacetate,

* Only if blood can be adequately screened

Blood transfussion in malaria
 Etiology Hypoglycemia

• Parasites required carbo-hydrat for metabolism

• Impaired gluconeogenesis
• Quinine induced insulin formation

( hyperinsulinisme )
• Raised Tumor Necrosis factor (TNF-alfa)
Mx. Hypoglycaemia :
• Chek in all impaired councious/ convulsion/ acidosis
• Common in children and pregnancy
• SM with jaundice or chronic liver disease
• Severe hyperparasitemia
• In the past assoc with Rx Quinine iv
Management SHOCK
 ACUTE KIDNEY INJURY (AKI)

• Malaria related Acute Kidney Injury (MAKI)

• Penurunan fungsi ginjal dalam 48 jam :

– Peningkatan serum kreatinin 0.3 mg/dL, atau
– Peningkatan serum kreatinn 50% dan nilai dasar, atau
– Penurunan urin output 0.5 ml/kg/jam untuk 6 jam

• WHO : serum kreatinin > 3 mg/dL

• Sering pada malaria dewasa dan jarang pada anak
Management AKI :
- 30 % non-oliguric
- ( oliguric : < 0.5 cc/kg/ hr)
- Se creatinine > 2 mg/dl, should check daily

Manajemen :
Klinis dehidrasi : lakukan re-hidrasi Na Cl 0.9%,
10 ml/kg/jam ( 500ml/jam untuk 50 Kg)
Mencegah kelebihan cairan : respirasi rate,
askultasi paru, JVP, Oksimetri nadi,
CVP mesti di evaluasi setiap 200 ml cairan.
CVP : 0 – 5 cm
Diuretic in oliguric AKI
 Mx Bleeding disorders
• Thrombocytopenia is common in malaria, bleeding is uncommon
• If bleeding occur, DIC should be suspected and related bacterial
sepsis
• Antibiotic treatment should always be given in children with SM
• Low-dose heparin, antithrombin or recombinant activated
Protein C therapy are no longer recommended for DIC, nor is
the use of fresh frozen plasma to correct laboratory clotting
abnormalities unless there is bleeding
• Platelets can be administered when the platelet counts are <
5000/mm3 regardless of bleeding or if there is significant
bleeding and counts are below 30 000/mm3 .
 MALARIA HEPATOPATHY
• Malaria Hepatopathy : to describe hepatocellular dysfunction
in cases of malaria. MH was diagnosed in pt having:
at least > 3x serum amino transferase.

rise of serum total bilirubin along more than 3 mg/dL

absence exposure to hepatotoxic drugs & viral hepatitus

clinical response to antimalarial drugs

• WHO 2015: Severe falciparum malaria with icterus: presence of
P.falciparum asexual parasitaemia, serum bilirubin >3 mg/dL, parasIte
count > 100 000/uL
 Management liver dysfunction

• Management the complication (Hypoglicemia>>)

• Malaria biliosa: injection vitamin K 10 mg/d IV for 3 days
• Additional aspect of managemet (fluid therapy, blood
transfusion, concomitant use of antibiotics, use of
anticonvulsants)
• Hepatic encephalopathy : treat accordingly
 ASIDOSIS METABOLIK
PENYEBAB
 MANAGEMENT ACIDOSIS
Bila ph < 7.10, beri 1-2 meq/kg/hr ( 1 ampul 100
meq HCO3/ 50 kg, diberikan 1-2 jam)
 HAEMOGLOBINURIA/ Black water fever

• Continue full dose anti malarial

• Transfusion until Ht > 20%

• Re-hydrasi , adequate urine output
• G-6-PD test ( +, stop primaquine )

• Alkalinisation urine : 100-150 meq/l Sodium bicarbonate

in 5% Dextrose
• If AKI , refer to Hemodialysis
 Respiratory distress/ hypoxemia
Etiology : - Metabolic acidosis
- Pulmonary edema/ ARDS
- Pneumonia
- Severe anaemia
Investigations :
- Kussmaul Breath, rales diffuse
- Saturation O2
- FBC
- Chest X-ray
Rx : - Oxygenation  sat. o2 > 90 %
- Oxygen 4 – 6 L/min
ARDS
 TINDAKAN

(b)  Pemberian furosemid 40 mg i.v, jika perlu diulang 1 jam atau dosis
ditingkatkan sampai 200 mg (maksimum), memonitor urin output dan
tanda- tanda vital. Dosis anak furosemid 1 mg/kgBB/kali, diulang 1 jam
, jika belum ada perbaikan.
(c)  Untuk kondisi mendesak / pasien keadaan kritis dimana pernafasan
sangat sesak, dan tidak mungkin dirujuk tindakan yang dapat dilakukan
adalah :
Atur posisi pasien 1⁄2 duduk
 Spesific supportive treatments
• ABC ( Airway-Breathing-Circulation )

• Inserted Guedel oropharyngeal airway  prevent aspiration

• Intubated  mechanical ventilation

• Nasogastric tube : regular sucction. Non-intubated adult,

naso gastric tube after 60 hours from admission
• Oral hygiene

• Urine catheters : measuring urine output

• Consciousness deterioration : CT scan/ MRI , to exclude

intracerebral bleeding/ raised ICP, brain edema/ herniation
 PEDOMAN CAIRAN
• Kebutuhan cairan pada malaria berat harus
diperhitungkan individual/ berbeda pada masing2
kasus.
• Ada kecenderungan overload/ edema paru. “ Keep the
patient (slightly) dry “
• Pada anak sering terjadi dehydrasi karena kesulitan
intake maupun demam yang lama.
• Pemberian cairan secara bolus/ cepat, baik colloid
maupun kristaloid adalah kontra-indikasi.
• Pada AKI/ asidosis, gagal rehydrasi  Dialysis
• Pada anak dengan anemia  transfusi darah
• Perlu sering evaluasi JVP, perfusi jaringan, produksi
 - PEDOMAN PEMBERIAN CAIRAN -
• Pada dewasa dan anak :
–Malaria Falsiparum Berat : cairan yang direkomendasikan ialah NaCl
0.9% ; pemberian albumin tidak bermanfaat dan meningkatkan mortalitas
(FEAST study), transfusi bila Hb < 7 gr% (dewasa)
–DEWASA : Cairan awal NaCl 0.9% 3-5ml/kgBB/jam, selama 6 jam
pertama, lanjut 2-3 ml/kgBB/jam , evaluasi tiap 6 jam.
–ANAK : Cairan awal NaCl 0.9% 3-5ml/kgBB/jam, dalam 3-4jam pertama,
dilanjutkan 2-3 ml/kgBB/ jam dekstrose 5% atau bila mungkin ( dipilih
0.45% NS/5% Dextrose)
–Monitoring elektrolit, gula darah dan koreksi seperlunya.
–Bila syok umumnya karena sepsis, beri anti-biotik
–Bila AKI/ oliguria, cairan 5 ml/kg BB iv bolus diikuti dengan RRT ( dialysis)
Mx Sepsis in Malaria
 J. Penanganan terhadap infeksi sekunder/ sepsis

• WHO (2015), merekomendasikan pemberian antibiotik broad-spektrum pada

malaria berat pada anak sampai dipastikan tidak ada infeksi bakterial.
• Setelah pengobatan anti-malarial, bila kondisinya memburuk dapat diartikan
adanya infeksi bakterial
• Bila pasien sudah negatif pemeriksaan malaria dan masih demam,
penyebabnya ialah infeksi bakterial seperti salmonella atau infeksi saluran
kemih
• Obat pilihan ialah Cephalosporin generasi III atau IV atau derivat
Carbapenem
 Precaution

• Hygiene precaution ( hand hygiene , aseptic

procedure )
• Stress ulcer prophylactis : PPI/ H2-blockers
• DVT prophylactis : low molecular heparin,
anti-thrombotic stockings or elastic bandages
• Mobilisation
 REKURENSI
Rekurensi : ditemukan kembali parasit aseksual dalam darah setelah
pengobatan selesai. Rekurensi dapat disebabkan oleh :
• Relaps : rekurens dari parasit aseksual setelah 28 hari pengobatan.
Parasit tersebut berasal dari hipnozoit P.vivax atau P.ovale.
• Rekrudesensi : rekurens dari parasit aseksual selama 28 hari
pemantauan pengobatan. Parasit tersebut berasal dari sisa parasit
sebelumnya diobati.
• Reinfeksi : rekurens dari parasit aseksual yang merupakan infeksi
baru dari stadium sporozoit.
PAKATUAN WO PAKALAWIREN
Till we meet again !
Dr. Paul Harijanto, Sp.PD-KPTI, FINASIM
Lecturer in Sam Ratulangi Medical Faculty
DEPT. INTERNAL MEDICINE
Bethesda Hospital –TOMOHON
NORTH-Sulawesi, INDONESIA

Telp.: +62-431-351046(Bethesda)
+62-812-431-2869 (HP)
E-mail : paulharijanto@gmail.com