malaria other complications
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Managementof
Other malarialcomplications
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Supportive and ancillary treatmentResuscitation
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Laboratory support
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Nursing care
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Severe anemia
Severe anemia: Hb
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Blood transfusion for severe anemia
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Abnormal bleeding and DIC Symptomatic bleeding amy be due to
thrombocytopenia or DIC.
Asymptomatic thrombocytopenia is very commonin falciparum malaria.
Transf use fresh blood, clotting factors, or plateletconcentrates in systemic bleeding or DIC.
Platelet transfusion is not recommended inasymptomatic thrombocytopenia or ecchymosis ofskin or subconjunctival or retinal hemorrhage.
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Hyperparsitemia
Definition There is not enough evidence to provide a
firm recommendation on the definition of
hyperparsitemia.
5% parasitemia in low-transmission
setting
10% in higher-transmission setting
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Hyperparsitemia
TreatmentHyperparasitemic patients with no other signs ofsevere disease should be treated with oral
artemisinin derivativesu
nder the followingconditions:
Patients must be monitored closely for the first 48h after the start of treatment
If the patient does not retain on oral medication,parenteral treatment should be given withoutdelay.
Non-immune patients with parasitemia of > 20%
should receive parenteral treatment.
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Exchange blood transfusion
Rationale Removing infected RBC from circulation ->
lower parasite burden
Reducing rapidly antigen load and parasite-derived toxins, metabolites and toxinmediators produced by the host
Replacing the rigidunparasitized R
BC bymore deformable cells-> alleviating
microcirculatory obstruction
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Exchange blood transfusion
WHO indication in 2000 Parasitemia >30% without severe disease
Parasitemia>10% with severe disease
Parasitemia >10% and failure to respond to
optimal chemotherapy after 12-24 h
Parasitemia >10% and poor prognostic
factors (eg elderly patients, shizonts)
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Exchange blood transfusion
WHO indication in 2006 No consensus on indications, benefits and
dangers involved, or on practical details eg.
volume of blood forEBT.
No recommendation regarding the use of
EBT
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Hypoglycemia
Pathogensesis Increased peripheral requirement for glucose
consequent upon anarobic glycolysis
Increased metabolic demands of the febrile illness
obligatory demands of the parasites which use
glucose as their fuel
failu
re of hepatic glu
coneogenesis andglycogenolysis
Quinine-induced hyperinsulinemia
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Hypoglycemia
Management In all suspected cases, 50 glucose 50 ml
should be given and followed by an IV
infusion of 5% or 10% dextrose.
Blood glucose level should be monitored to
regulate the dextrose infusion.
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Treatment of hypoglycemia
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Treatment of convulsions
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Shock/circ
ulatory collapse
Correct hypovolemia with appropriate fluid
Look for possible sites of infection
Take blood culture and start broad-spectrum
antibiotics, eg 3rd generation
cephalosporins
If patients do not respond to adequate fluid
therapy, ionotropic agents are helpful.
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Fluids
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Concomitant use of antibiotics in
severe malaria Threshold for administering antibiotic treatment
should be low in severe malaria.
Septicemia and severe malaria are associated andthere is diagnostic overlap, particularly inchildren.
Enteric bacteria (notably Salmonella) have
predominated in most trial series, a variety ofbacteria have been cultured from blood of severemalaria patients. Broad-spectrum antibiotic shouldbe given initially.
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Broad-spectrum IV antibiotics
Severely ill or shocked patients
Unconscious patients
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Metabolic acidosis
Pathogenesis Severe dehydration is the most important
contributor
Blood lactate levels rises due to tissue
hypoxia, increased body metabolism, and
failure of hepatic clearance of lactate -> loss
of bicarbonate ->metabolic acidosis
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Metabolic acidosis
Clinical features Hyperventilation
Kussmauls breathing
Chest signs are usually absent.
Presence of chest signs (crepitations and/orrhonchi) is indicative of pulmonary
edema/ARDS or associated pneumonia. Arterial pH and plasma bicarbonate will
confirm the diagnosis.
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Jaundice
Pathogensis: Hemolysis and hepatic dysfunction
Liver failure with hepatic encephalopathy is rare.
Jaundice is considered as severe malaria in WHO 1990 and
2006 criteria as it may be associated with vital organdysfunction.
Jaundice with vital organ dysfunction indicates severe
disease. In WHO 2000 criteria, jaundiceper se without
vital sign dysfunction is not considered severe malaria.
Jaundice is more common in adults than in children.
No specific treatment.
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Blackwater fever
Uncommon
Causes: - massive hemolysis in normal G6PD
- hemolysis in G6PD deficiency Mortality is high when it is associated with severe
malaria and other vital organ dysfunction.
Not associated with significant renal impairment
Usually transient and resolves withoutcomplications; in severe cases renal failure maydevelop.
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F
ever Paracetamol 15 mg/kg 4-hourly, may be
given PO or PR.
Tepid sponging and fanning to try to keep
the rectal temperature < 39 C; May ask
relatives to do this.
NSAID is not recommended and may causeGI bleeding.
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Unproved or harmful adjuvants Heparin
Prostacyclin
Desferoxamine
Pentoxifylline
Low molecular weight dextran
Urea
Corticosteroids
Acetylsalicylic acid
Anti-tumor necrosis factor Ab
Cyclosporin Dichloroacetate
Adrenaline
Hyperimmune serum
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Severe anemia
Give blood transfusion in
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