Severe Malaria

Clinical Description

Most severe malaria occurs in children under 5 years of age. Severe malaria is a medical emergency and as such treatment should begin immediately, whether the patient presents at the community, health center, or hospital level. Suspect severe malaria if a patient has one or more of the following conditions (mostly seen in combination):

Clinical manifestations and some laboratory findings

Clinical manifestations Some laboratory findings

• Impaired level of consciousness (cerebral malaria)
• Respiratory distress (acidotic breathing)
• Repetitive
• convulsions
• Circulatory
• collapse
• Pulmonary
• oedema
• Prostration
• Excessive or persistent vomiting
• Extreme pallor Shock (weak pulse, cold extremities)

Jaundice (yellowish coloration of eyes) Little or no urine output (think about acute

• Severe anaemia: (Hb<5 g/dl) (i.e. Hb <5 g/dl or Hct < 15 %)
• Hypoglycaemia: (<2.2
• mmol/l or <40 mg/dl)
• Hyperlactataemia (lactic acidosis) (blood lactate >4 mmol/l)
• Electrolyte imbalance
• (hyponatraemia)
• Acute kidney injury
• (serum creatinine
• >265 μmol/l)
• Haemoglobinuria kidney injury) Very dark colored urine
• Spontaneous bleeding (mouth, nose, skin, eyes)
• Hypovolaemia
• Although most children with malaria have a (history of) fever, this may be variable in patients who have progressed to severe malaria
• Examine children with suspected severe malaria for other conditions (e.g.

pneumonia, meningitis) as a possible cause of their symptoms and, if found, manage appropriately

Note:

• Patients with hyperparasitaemia: 4+ (40,000 - 400,000/μl or ring stage >5% of RBCs) who do not have any of these indicators of severe (disease) malaria should be admitted for observation. Treat with first-line antimalarial (LA).

If severe malaria is diagnosed in an out- patient, refer the child for hospitalization (see below)

PRE-REFERRAL TREATMENT AT COMMUNITY LEVEL

Refer any patient with severe malaria to the nearest hospital

Treatment

• Give Rectal Artesunate at 10 mg/kg body weight in a single dose, followed as soon as possible by definitive therapy for severe malaria at a hospital
• In the event that Artesunate Suppository is expelled from the rectum within 30 minutes of insertion, a second suppository should be inserted
• If referral is not possible within 12 hours, a second dose of Rectal Artesunate should be administered at 12 hours after the initial dose, then once in every 24 hours until patient is transferred to a hospital

Initial (pre-referral) Dosage of Artesunate Suppositories for patients aged >6 yrs

Weight (kg) Artesunate dose Regimen (single dose) <40 10 mg/kg Use appropriate no. of 50 mg rectal suppositories 40 -59 400 mg Two suppositories of 200 mg each 60 -80 800 mg Four suppositories of 200 mg each >80 1200 mg Six suppositories of 200 mg each

Note:

• For children, hold the buttocks together for 10 minutes to ensure retention of the rectal dose
• Treatment with Rectal Artesunate is suboptimal, and every effort should be made to refer the patient as soon as possible
• The table below shows the recommended pre-referral doses of Artesunate

Suppositories for children aged <6 years

• As in adult patients, if referral is not possible within 12 hours, a second dose of Rectal Artesunate should be administered at 12 hours after the initial dose

Thereafter the dose may be repeated every 24 hours. Refer to the malaria treatment guidelines for RA insertion procedure

Initial (pre-referral) Dosage of Artesunate Suppositories for Children Aged 2months -15

Years (and weighing at least 5 kg)

Weight (kg) Age Artesunate dose (mg)

Regimen (single dose) 5 - 8.9 2 – 12 months 50 One 50 mg suppository 9 - 19 13 – 42 months 100 Two 50 mg suppositories 20 - 29 43 – 60 months 200 One 200 mg suppository 30 - 39 6 years 200 One 200 mg suppository

Note: Do not give rectal Artesunate to patients above 6 years of age

PRE-REFERRAL TREATMENT AT HEALTH CENTRE LEVEL

Treatment

• Give Artesunate 3 mg/kg in children <20kg and 2.4 mg/kg (0.12 ml/kg) >20kg and adults IM
• Artesunate should be given by intramuscular injection into the upper- outer quarter of anterior thigh and should not be injected into the buttocks
• To administer IM Artesunate, weigh the patient and determine the number of vials needed for treatment as per the table below:

Number of Required Vials of Parenteral Artesunate by Body Weight

Weight 60 mg vials required 5 kg - 25 kg 1 26 kg - 50 kg 2 51 kg - 75 kg 3 76 kg - 100 kg 4

• Each 60 mg vial of injectable Artesunate must be reconstituted with 1 ml of Sodium

Bicarbonate

• Dilute the Artesunate-Bicarbonate mixture with 2 ml of 5% Dextrose Solution or Normal Saline (0.9% Sodium Chloride) to produce a 20 mg/ml solution. Never use water for injection
• Withdraw the appropriate volume in a syringe ([2.4 mg x body weight in kg]/20 mg/ml) for intramuscular injection, rounding to the next whole number in milliliters
• Administration of pre-referral IM Artesunate 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 Artesunate should be administered at 12 hours after the initial dose
• If referral is still not possible after 24 hours, a third dose of IM Artesunate should be given

Alternatively

• If IM Artesunate is unavailable or contraindicated, treat with high dose Quinine IM, administered in the thigh not the buttock
• Give IM Quinine 10 mg (0.2 ml) per kg body weight
• If the volume to be injected exceeds 3 ml, give half into each thigh. An example of body weights and dosing (ml) for IM quinine is given in the table below.

Dosage o/ Parenteral Quinine per body weight

Body weight Quinine (ml) Number of injection sites

Under 5 kg 1.0 ml 1 5.1 -7.5 kg 1.5 ml 1 7.6 -10.0 kg 2.0 ml 1 10.1 -12.5 kg 2.5 ml 1 12.6 -15.0 kg 3.0 ml 1