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8. Treatment of severe P. falciparum malaria

presentation. Although quinine can cause hypotension if administered rapidly, and
overdose is associated with blindness and deafness, these adverse effects are rare in
the treatment of severe malaria. The dangers of insufficient treatment (i.e. death from
malaria) exceed those from excessive treatment initially.

8.7.3 Adjustment of dosing in renal failure or hepatic dysfunction
The dosage of artemisinin derivatives does not need adjustment in vital organ dysfunction.
Quinine (and quinidine) levels may accumulate in severe vital organ dysfunction. If the
patient remains in acute renal failure or has hepatic dysfunction, then the dose should
be reduced by one third after 48 h. Dosage adjustments are not necessary if patients are
receiving either haemodialysis or haemofiltration.

8.8 adjunctive treatment

In an attempt to reduce the unacceptably high mortality of severe malaria, various
adjunctive treatments for the complications of malaria have been evaluated in clinical
trials. These are summarized in Table 8.1, and further information is given in sections
8.9 and 8.10.

table 8.1 immediate clinical management of severe manifestations and complications
of P. falciparum malaria
manifestation/complication immediate management a
coma (cerebral malaria) Maintain airway, place patient on his or her side, exclude other treatable
causes of coma (e.g. hypoglycaemia, bacterial meningitis); avoid harmful
ancillary treatment, such as corticosteroids, heparin and adrenaline; intubate
if necessary.
Hyperpyrexia Administer tepid sponging, fanning, a cooling blanket and antipyretic drugs.
Paracetamol is preferred over more nephrotoxic drugs (e.g. NSAIDs ).
b
convulsions Maintain airways; treat promptly with intravenous or rectal diazepam or
intramuscular paraldehyde. Check blood glucose.
Hypoglycaemia Check blood glucose, correct hypoglycaemia and maintain with glucose-
containing infusion.
severe anaemia Transfuse with screened fresh whole blood.
acute pulmonary oedema c Prop patient up at an angle of 45°, give oxygen, give a diuretic, stop
intravenous fluids, intubate and add positive end-expiratory pressure/
continuous positive airway pressure in life-threatening hypoxaemia.
acute renal failure Exclude pre-renal causes, check fluid balance and urinary sodium; if
in established renal failure add haemofiltration or haemodialysis, or if
unavailable, peritoneal dialysis.
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