Malaria Management System in Malaysia

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For your information, the following is the management guideline for malaria

1. Take a complete history and physical examination.
   a. Examine the Glasgow Coma Scale (GCS), presence of neck stiffness, Blood pressure, Pulse rate, Respiratory rate. Examine the fundi as well.
2. Send the following investigations:
   a. Blood for Culture and Sensitivity.
   b. Full Blood Count.
   c. Prothrombin Time (PT), Partial Thromboplastin Time (PTT).
   d. Serum Urea and Electrolytes, Creatinine.
   e. Blood glucose.
   f. Liver Function Test.
   g. Chest X-ray.
   h. Arterial Blood gas.
   i. Serum Lactate (if available)
3. Admit the patient to the ICU or the High Dependency Unit
4. The patient should be referred to the Physician or the Intensivist.
5. Give IV Artesunate (2.4 mg/kg) stat. If this is not possible, give it IM. Administer IV Quinine if IV Artesunate is not available (and IM, if no IV access). For complete dosing, please look at the section on antimalarial treatment.
6. Administer the intravenous antimalarial for at least 24 hours before switching to an oral formulation if the patient improves and can tolerate it orally.
7. Close observation of the vital signs, GCS, by the nurses and doctor is of vital importance
8. Pulmonary oedema is a grave complication of severe knowlesi and falciparum.
   It has a high mortality (over 80%in falciparum malaria); the prognosis is better in vivax malaria.
   Pulmonary oedema may develop several days after the chemotherapy has been started, at a time when
   the patient’s general condition is improving and the peripheral parasitaemia is falling.
   a. Close input-output monitoring is very important as the patient can develop pulmonary oedema
   easily if too many fluids are given. Give fluids just enough to maintain circulation and correct
   dehydration.
   b. Children with severe malaria who are unable to retain oral fluids should be managed with half
   normal saline (0.45%) with 5% dextrose with maintenance fluids (3-4ml/kg/hour), and adults at
   1-2ml/kg body weight per hour, until the patient, is able to take and retain oral fluids.
   c. Rapid fluid boluses are contraindicated in severe malaria resuscitation. Dehydration should be
   managed cautiously and ideally guided by urine output (with a urine output goal of > 1ml/kg body
   weight per hour) unless the patient has anuric renal failure or pulmonary oedema, for which fluid
   management should be tailored to the needs of the patient and reassessed frequently.
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   Management Guidelines Of Malaria In Malaysia Management Guidelines Of Malaria In Malaysia
   Manifestations/
   Complications
   Immediate Management
   Coma
   (cerebral malaria)
   • Maintain airways and for ventilator support if necessary; exclude other treatable
   causes of coma (e.g. hypoglycaemia, bacterial meningitis); avoid harmful ancillary treatment, such as corticosteroids, heparin and adrenaline.
   Convulsions
   • Maintain airways; treat promptly with intravenous or rectal diazepam and/ or other
   anticonvulsants. Check blood glucose, blood urea and serum electrolytes.
   • Prophylactic anticonvulsants are not recommended.
   Hypoglycaemia • Correct hypoglycaemia and maintain with glucose containing infusion
   Acute renal failure • Exclude pre-renal causes, check fluid balance and urinary sodium in established
   renal failure initiate haemofiltration or haemodialysis, or peritoneal dialysis.
   Severe Anaemia • Blood transfusion where indicated.
   Acute pulmonary
   oedema
   • Prop patient up at an angle of 45°, give oxygen and other respiratory support as
   indicated. Adjust fluid therapy appropriately. Diuretics if necessary.
   Shock
   • Assess hydration status. Give appropriate fluid therapy Achieve CVP
   measurement 8-12cm H2O. Suspect septicaemia (bacterial in origin) in
   unexplained clinical deterioration. Take blood for cultures; give parenteral
   broad-spectrum antimicrobials and change it according to culture results.
   6.7 Adjunct therapy
   In an attempt to reduce the unacceptably high mortality of severe malaria, besides appropriate and
   effective antimalarial drugs, various adjunctive treatments for the complications of malaria have
   been evaluated in clinical trials. Adjunctive therapy is defined as any additional therapy that modifies
   physiologic processes caused by malaria. These therapies may act directly on specific biologic pathways
   altered by malaria or more generally on end-stage factors produced in malaria by a number of different
   specific processes.
9. If the patient‘s GCS is reduced, look for other causes such as meningitis. A lumbar puncture may
   then be indicated and antibiotics instituted.
10. There is considerable clinical overlap between septicaemia, pneumonia and severe malaria, and
    these conditions may coexist .If secondary infections are suspected, then start the patient on a
    broad spectrum IV antibiotic such as Ceftriaxone 2g OD ( after a septic workout is done).
11. Monitor for clinical and parasitological therapeutic response.
12. High fever can be managed by tepid sponging and Paracetamol.

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