From the Guidelines
The patient should receive intravenous artesunate as first-line treatment for severe Plasmodium falciparum malaria, administered for 3 doses, as it is the recommended treatment by WHO and has shown faster parasite clearance time and shorter ICU stay compared to quinine 1. The treatment for a 50-year-old male with positive malaria presenting to the ER with severe hypotension, severe respiratory distress, and altered mental status requires immediate intensive care management.
- Key aspects of treatment include:
- Intravenous artesunate as first-line therapy, given its approval by the Food and Drug Administration and the European Medicines Agency, and its demonstrated benefits in severe falciparum malaria 1
- Administration of artesunate for 3 doses, with a switch to an available artemisinin-based combination therapy (ACT) once the patient is clinically improved and able to take oral treatment 1
- Restrictive fluid management to avoid pulmonary or cerebral edema, as it does not worsen kidney function or tissue perfusion 1
- Consideration of acetaminophen for its potential reno-protective effect in acute kidney injury, as demonstrated in small open-label trials 1
- Initiation of antibiotics if a concomitant bacterial infection is suspected, with continuation only if blood cultures are positive 1
- Supportive care is crucial and includes:
- Immediate fluid resuscitation with crystalloids
- Vasopressors for persistent hypotension
- Intubation with mechanical ventilation for respiratory support
- Close neurological monitoring
- Frequent blood glucose checks due to the risk of hypoglycemia
- ICU admission with continuous cardiac monitoring, hourly vital signs, and serial blood tests to manage potential complications and multi-organ dysfunction.
From the Research
Treatment Approach
The treatment for a 50-year-old male with positive malaria (Plasmodium falciparum) presenting to the emergency room with severe hypotension, severe respiratory distress, and altered mental status involves:
- Immediate administration of intravenous artesunate, as it has been shown to be more effective than quinine in treating severe falciparum malaria 2
- Consideration of fluid resuscitation to improve organ perfusion and correct metabolic acidosis, but with caution to avoid aggravating intracranial hypertension associated with cerebral malaria 3
- Potential use of a combination of artesunate and quinine, as this approach has been found to be efficacious and safe in some cases 4, 5
Medication Administration
- Intravenous artesunate should be administered at a dose of 2.4 mg/kg bodyweight given as a bolus at 0,12, and 24 hours, and then daily 2
- Intravenous quinine can be used in combination with artesunate, but its use should be carefully considered due to the risk of hypoglycemia 2
Monitoring and Support
- Close monitoring of the patient's vital signs, including blood pressure, respiratory rate, and level of consciousness
- Supportive care, such as mechanical ventilation, may be necessary in cases of severe respiratory distress or acute respiratory distress syndrome 4
- Careful management of fluid resuscitation to avoid complications associated with cerebral malaria 3