17.5 Kg 3.5 Ml 2

Clinical Description

17.6 -20.0 kg 4.0 ml 2 20.1 -22.5 kg 4.5 ml 2 22.6 -25.0 kg 5.0 ml 2 25.1 -27.5 kg 5.5 ml 2 27.6 -30.0 kg 6.0 ml 2

• Administration of pre-referral IM Quinine should be followed as soon as possible by definitive therapy for malaria at a hospital
• If referral is not possible within 12 hours, a second dose of IM quinine should be administered 12 hours after the initial dose
• If referral is still not possible after 24 hours, a third dose of IM Quinine should be given
• Give 0.4ml/kg of this solution as the first
• (loading) dose - this is 20mg/kg
• Subsequent (12-hourly) doses should each be 0.2ml/kg (10mg/kg)
• The dose of Quinine for an adult at anyone time should not exceed 1,200mg

Injectable artesunate or quinine should be for patients unable to take oral drugs.

• Where there is no scale, weight of the child can be estimated as follows:
• For children of 3months to 12months old
• Weight (Kg) = Age (months) + 9/2
• For children of 1 year to 6years old
• Weight (Kg) = [Age (in years) x 2) + 8

If IM Artesunate and IM Quinine are unavailable

• Give Rectal Artesunate

ADDITIONAL MANAGEMENT AND SUPPORTIVE MEASURES

Reduce fever:

• Tepid sponging with lukewarm (not cold) water
• Give an antipyretic (paracetamol 10 mg/kg; 6 to 8-hourly) as required until fever is reduced. See dose tables in Section 10.1

Take 8 immediate measures:

• 1. Start resuscitation, particularly maintenance of a patent airway.
• 2. Establish IV line.
• 3. Make a thick blood smear for immediate malaria parasite count, (if microscopy is not available, an mRDT may be useful to indicate whether malaria infection is present or not)
• 4. Classify the degree of dehydration, assess patient's fluid requirements and correct accordingly.
• 5. Control fever if the axillary temperature is 38.5QC or above: Tepid sponge, fanning and oral or rectal paracetamol (15 mg/kg every 4 to 6 hours).
• 6. Control convulsions: maintain airway, treat with rectal diazepam (0.5 mg/kg) or slow IV diazepam (0.3 mg/kg, maximum 10 mg in an adult), or paraldehyde 0.1 ml/kg IM. Remember to correct any hypoglycaemia or hyperpyrexia in a convulsing patient.
• 7. Detect and treat hypoglycaemia: hypoglycaemia can be induced by high parasitaemia, fasting and quinine therapy. Hypoglycaemia can recur, especially in pregnant women and children. If blood glucose 3 mmol/l or 54 mg/dl; give 1 ml/kg of 50% dextrose IV, diluted with an equal volume of 0.9% saline or 5% dextrose, give slowly over 3-5 minutes, and check blood glucose after 30 minutes and as required after treatment. Follow with 10% dextrose infusion at 5 ml/kg/hr. If there is no test for blood glucose, treat as if the patient is hypoglycaemic.
• 8. Start intravenous or intra-muscular artesunate. Dosage schedule is provided from section 2.2.2.2 below. If intravenous or intra-muscular artesunate is unavailable, use intravenous or intra-muscular quinine.

LOOK FOR AND DEAL WITH THE FOLLOWING 8 COMPLICATIONS:

• 1. Shock: If cold peripheries, delayed capillary refill, or Systolic BP <50 mmHg in children 1 - 5years or <80 mmHg >5 years, suspect Gram-negative septicaemia. In such cases take blood samples for culture. Give parenteral broad-spectrum antimicrobials. Correct fluid disturbance, and then continue with maintenance fluid as follows: for children weighing <10 kg, give 4 ml/kg/hr.;
• for children weighing 10 - 20 kg, give 40 ml/hr. plus additional 2 ml per kg for each kg of weight in excess of 10 kg;
• for children weighing >20 kg, give 60 ml/hr., plus additional 1 ml per kg for each kg of weight in excess of 20 kg. Give oxygen if possible.

2 Severe anaemia: Consider the need for blood transfusion: Assess the degree of pallor (no pallor, some pallor or severe pallor - look especially at palms of hands, also mucous membranes). Assess signs that increase the danger of severe anaemia - respiratory distress, altered consciousness, shock and hyper-parasitaemia.

Note: The decision to transfuse with blood should not only be based on low laboratory values, but on a full assessment of the patient**. As a guide, all patients with PCV<12% or Hb<4 g/dl should be transfused, whatever the clinical state; those with any of the above danger signs may be transfused even if PCV is 13-18% or Hb 4-6g/dl.

• Transfuse packed red cells in most cases; in shock or severe acidosis, use whole blood. The volume transfused should be 20 ml/kg.
• Metabolic acidosis (deep, fast breathing): exclude or treat hypoglycaemia, hypovolaemia and gram negative septicaemia. Give isotonic saline 20 ml/kg of body weight rapidly or screened whole blood 10 ml/kg if PCV <18% or Hb<6 g/dl.

Consider lactic acidosis and enquire whether the patient has been taking ART (lactic acidosis is a side effect of stavudine).

• Spontaneous bleeding or coagulopathy: If patients have underlying malnutrition, concomitant hepatic obstruction and bile salt excretion defects or prolonged fasting for more than 3 days, transfuse screened fresh whole blood, give Vitamin

K 10 mg IV slowly once a day for 3 days. For Children give 2 - 3 mg/day slow IV.

Vitamin K injections should not be given to "all" severe malaria patients with spontaneous bleeding, the risks and benefit of Vitamin K administration should be considered. Serious adverse events of Vitamin K injection include hypotension, difficulties in breathing, bradycardia or anaphylaxis.

• Acute pulmonary oedema in adults: prevent by avoiding excessive rehydration.

Treatment: prop patient up; give oxygen. Stop IV fluids if pulmonary oedema is due to over-hydration, give a diuretic (furosemide IV 40 mg for adult and 0.5 - 1 mg/kg/dose for children).

• Acute respiratory distress syndrome:
• supportive treatment +/- ventilation
• Acute kidney injury in adults: detect this by monitoring fluid balance. Identify and correct any dehydration or hypovolaemia. Maintain strict fluid balance. Consider peritoneal dialysis if oliguria persists beyond a few days.
• Common infections and other conditions that present like severe malaria: Perform urinalysis, lumbar puncture (unless contraindicated), blood culture if possible, and chest x-ray.

Box 3: Monitor the Following 8 Observations:

Where possible use Critical Care Pathways (CCPs).

• 1. Level of consciousness (using coma score)
• 2. Vital signs every 4 hours (temperature, 3. pulse, respiration, blood pressure)
• 4. Fluid balance (urine volumes, intake volumes - IV and oral - puffy eyes, chest crepitation, elevated jugular venous pressure)
• 5. Increasing anaemia (pallor, heart failure with increasing liver size)
• 6. Occurrence of convulsions -see item 2 in 7. previous Box
• 8. Blood glucose every 4 hours’ while 9. unconscious and also if convulsions occur 10. [Hb]/Packed Cell Volume -at least daily, or more often if anaemia is suspected
• 11. Ability to suck, drink, eat, sit and walk -measures of overall strength.

MANAGEMENT OF SEVERE MALARIA IN PAEDIATRIC IN-PATIENTS

Treatment

• Give Artesunate 2.4 mg/kg body weight IV for adults of 20kg or more and 3.0mg/kg body weight for children of 20kg or less) on admission (at 0 hour)
• Repeat at 12 hours and 24 hours, after initiating the first dose then once daily for not more than six days
• Switch to LA once the patient can take oral treatment after at least 24 hours of Parenteral Artesunate
• There should be an interval of at least 8 hours between the last dose of Artesunate and the first dose of LA

Alternatively

• Give Artesunate 2.4 mg/kg or 3.0mg/kg body weight for children less than 20 kg IM into the upper-outer quarter of anterior thigh if intravenous bolus is not feasible
• Note: Artesunate solution should be freshly prepared prior to administration and should never be stored

In case Artesunate is not available or is contraindicated, then

• Give Parenteral Quinine
• Refer to section 15.1.2.1 to determine the number of vials needed for treatment
• For children, Quinine IV is administered as follows:
• Initial (loading) dose 20 mg (Quinine Salt)/kg body weight: inject this dose into 10 ml/kg of 5% Dextrose or half strength Darrow's and infuse over 3-4 hours
• If patient has already received Quinine for this illness, the first dose IV infusion should be 10 mg/kg diluted as above and given over 3-4 hours with no loading dose
• Subsequent doses of 10 mg/kg should be given every 12 hours
• The infusion should run for 3 - 4hours. Continue the 5% Dextrose or half strength Darrow's IV fluid (10 ml/kg given over 3 - 4 hours) between doses of quinine
• Switch to LA once the patient can take oral treatment after at least 24 hours of Parenteral Quinine

Note: LA should only be taken 12 hours after last dose of quinine to avoid cardiotoxicity

MANAGEMENT OF SEVERE MALARIA IN ADULT IN-PATIENTS

Treatment

• If the patient can be weighed, intravenous Quinine is administered in the same manner as for children
• If the patient cannot be weighed, IV Quinine should be given as follows:
• First dose 900 mg in one litre of 5% Dextrose or 1⁄2-strength Darrow's

Fluids given over 3 - 4 hours

• Subsequent doses 600 mg in one litre 5% Dextrose or 1⁄2-strength

Darrow's Fluids q12h given over 3 - 4 hours

• Continue the same IV fluids or Ringer's Lactate (10 ml/kg given over 3 - 4 hours) between doses of Quinine (Give a maximum of about 3 litres per 24 hours to avoid fluid overload)
• Stop intravenous Quinine as soon as the patient can take food and fluids orally and at least 24 hours of Parenteral Quinine has been administered

Note: What if 60+ kg?

• Give the appropriate dose of LA beginning 12 hours of the last dose of quinine for 3 days. For pregnant women in the first trimester give oral quinine plus clindamycin for a total of 7 days

COMPLICATION THAT MAY ARISE IN ADULTS

• Apart from cerebral malaria and anaemia, in adults’ other complications may develop such as:
• Acute renal failure
• Respiratory distress syndrome (presenting as severe breathlessness)
• Disseminated intravascular coagulation (DIC) - presenting as prolonged or spontaneous bleeding
• Jaundice from severe haemolysis or liver cell damage
• Management must be appropriate to each complication that develops
• Fluid and antimalarial drugs are given as for children

TREATMENT OF SEVERE MALARIA IN PREGNANCY

Treatment

• Parenteral artesunate is the recommended treatment for severe malaria in all the trimesters of pregnancy.
• Refer to 15.1.2.5

Note: Random blood glucose should be measured before and after quinine administration

• Shift to LA as soon as the patient is able to take oral medication and at least 24 hours of parenteral therapy has been administered (refer to malaria treatment guidelines for details)
• Special attention must be paid to anaemia, hypoglycaemia and pulmonary oedema

See below for further information on the management of complications

BOX 4: MANAGEMENT OF COMPLICATIONS: (SEE THE 8- 8- 8 SCHEDULE

ABOVE)

Manage complication as for any adult. Of special importance in pregnancy are:

• Pulmonary oedema: careful fluid management, diuretics if necessary, oxygen if possible, nurse patient in semi- upright position.
• Hypoglycaemia: consider this complication if there is altered consciousness or seizure.
• Treat as in Item 2 in Box 2.
• Anaemia: be prepared for blood transfusion, especially if the patient is close to parturition. Otherwise, indications for blood transfusion are the same as in others - (see Box 2).
• Acute kidney injury: a particular danger if there has been eclampsia or shock.

Identification and management as above.

• Shock: consider concealed haemorrhage, continuing blood loss, and septicaemia.

Pay special attention to fluid needs. Culture blood if possible. Administer broad spectrum antibiotics in addition to quinine.

MALARIA: SELECTIVE CHEMOPROPHYLAXIS

The appropriate regimen for an individual depends on the circumstances.

Risk Groups

The following high-risk groups should be given antimalarial chemoprophylaxis:

• Patients with immunosuppression caused by illness (e.g. Leukaemia, but not HIV infection or malnutrition) or splenectomy
• Tropical splenomegaly syndrome
• Under 5s with recurrent febrile convulsions
• Individuals with sickle cell disease
• Non-immune visitors (i.e. visitors from non-malarial countries)
• Pregnant women

ANTIMALARIAL PROPHYLAXIS REGIMENS

• Give Mefloquine (Lariam) 250 mg weekly
• Contraindicated in pilots, people with history of cardiac disease, neurological disease or depression, and in those taking beta-blocking drugs

Give Atovaquone-proguanil ('Malarone') - one tablet daily

• Take for only one week after exposure end Give Chloroquine 300 mg - 2 tablets weekly Should be combined with daily proguanil (see below)
• Chloroquine causes itching in 40% of black people. Contraindicated in persons with psoriasis or epilepsy
• Risk of retinal damage if taken every week for more than 6 years - advise a change
• Give Proguanil (Paludrine®) 200 mg daily
• Should combine with an additional drug such as weekly Chloroquine