What is the treatment for complicated malaria?

Treatment of Complicated Malaria

Intravenous artesunate is the first-line treatment for complicated malaria and should be administered immediately as a medical emergency at a dose of 2.4 mg/kg at 0,12, and 24 hours, then daily until oral medication can be taken. 1

Diagnosis of Complicated Malaria

Complicated malaria is diagnosed based on the following WHO criteria:

• Impaired consciousness or coma 1
• Multiple convulsions (>2 seizures within 24h) 1
• Respiratory distress or irregular breathing 2
• Hypoxia (oxygen saturations <95%) 2
• Evidence of shock (tachycardia, hypotension, cold extremities) 2
• Severe dehydration 2
• Metabolic acidosis (base deficit >8) 2
• Severe hyperkalaemia (potassium >5.5 mmol/l) 2
• Hypoglycemia (<40 mg/dL) 1
• High parasitemia 1
• Jaundice 1
• Acute kidney injury 1

First-Line Treatment

• Administer intravenous artesunate immediately at 2.4 mg/kg at 0,12, and 24 hours, then daily until the patient can take oral medication 1
• Follow with a complete course of oral artemisinin-based combination therapy (ACT) once the patient improves 1
• If artesunate is unavailable, use intravenous quinine as an alternative (20 mg/kg loading dose diluted in 20-40 ml and run over 4 hours) 2, 3
• Monitor for hypoglycemia when using quinine, as it may exacerbate this complication 3

Supportive Management

• Airway management: Check for irregular breathing patterns and provide oxygen if saturations <95% 2
• Fluid management: Use restrictive fluid management to avoid pulmonary or cerebral edema 1
  • For shock: Administer 20 ml/kg bolus of colloid, 0.9% saline, or 4.5% albumin if child is in coma 2
  • If no response/worsening shock: Repeat 20 ml/kg bolus; after 40 ml/kg, consider central venous pressure monitoring 2
• Acetaminophen: Consider for reno-protective effects in acute kidney injury (1g every 6 hours for 72 hours) 2, 1
• Antibiotics: Start empirically if bacterial co-infection is suspected, especially in children, but continue only if blood cultures are positive 2, 1
• Seizure management: Treat status epilepticus according to standard protocols 2

Monitoring During Treatment

• Parasitemia: Monitor every 12 hours until decline to <1%, then every 24 hours until negative 2, 1
• Continuous monitoring of:
  • Cardiocirculatory parameters 2
  • Pulmonary function 2
  • Renal function 2
  • Metabolic parameters (glycemia, plasma bicarbonate, lactate) 2, 1
• Post-artesunate delayed hemolysis (PADH): Monitor hemoglobin, haptoglobin, and lactate dehydrogenase levels at days 7,14,21, and 28 2, 1

Special Considerations

• Pregnancy: Intravenous artesunate is preferred over quinine for severe malaria in any trimester 3
• Children: Require the same urgent treatment as adults with appropriate weight-based dosing 3
• Renal failure: Consider early renal replacement therapy 4, 5
• Respiratory distress: May require mechanical ventilation 5

Common Pitfalls to Avoid

• Delaying treatment while awaiting confirmation: Start treatment empirically if clinical suspicion is high 1, 3
• Inadequate monitoring: Patients with severe malaria require intensive care monitoring 3
• Exchange blood transfusion: Not recommended as it has not been shown to improve outcomes 2, 1
• Oral medications in patients with impaired consciousness: Always use parenteral therapy until the patient can reliably take oral medication 3

Remember that complicated malaria is a medical emergency requiring immediate treatment to prevent progression to death. The mortality rate remains high despite advances in treatment, making rapid diagnosis and appropriate management crucial for patient survival 4.