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Guidelines for the treatment of malaria – 2 edition

table 8.1 continued
manifestation/complication immediate management a
spontaneous bleeding and Transfuse with screened fresh whole blood (cryoprecipitate, fresh frozen
coagulopathy plasma and platelets, if available); give vitamin K injection.
metabolic acidosis Exclude or treat hypoglycaemia, hypovolaemia and septicaemia. If severe,
add haemofiltration or haemodialysis.
shock Suspect septicaemia, take blood for cultures; give parenteral broad-spectrum
antimicrobials, correct haemodynamic disturbances.
a. It is assumed that appropriate antimalarial treatment will have been started in all cases
b. Non-steroidal anti-inflammatory drugs
c. Prevent by avoiding excess hydration

8.9 continuing supportive care

Patients with severe malaria require intensive nursing care, preferably in an intensive care
unit where possible. Clinical observations should be made as frequently as possible. These
should include monitoring of vital signs, coma score, and urine output. Blood glucose should
also be monitored every four hours, if possible, particularly in unconscious patients.
Fluid requirements should be assessed individually. Adults with severe malaria are very
vulnerable to fluid overload. Children, on the other hand, are more likely to be dehydrated.
The fluid regimen must also be tailored around infusion of the antimalarial drugs.
Central venous pressure should be maintained at 0–5 cm. If available, haemofiltration
should be started early for acute renal failure or severe metabolic acidosis, which are
unresponsive to rehydration.
If blood glucose is < 2.2 mmol/l, then hypoglycaemia should be treated immediately
(0.3–0.5 g/kg body weight of glucose). Hypoglycaemia should be suspected in any patient
who deteriorates suddenly.
Patients with severe malaria with clinically significant disseminated intravascular
coagulation should be given fresh whole blood transfusions and vitamin K.
Patients with secondary pneumonia or with clear evidence of aspiration should be given
empirical treatment with a third-generation cephalosporin, or the appropriate antibiotic
of known sensitivity in that locality. In children with persistent fever despite parasite
clearance other possible causes of fever should be excluded. This includes a systemic
Salmonella infection and urinary tract infections, especially in catheterized patients.
However, in the majority of cases of persistent fever, no other pathogen is identified
after parasite clearance. Antibiotic treatments should be based on culture and sensitivity
results, or, if not available, take into account likely local antibiotic sensitivity patterns.

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