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8. Treatment of severe P. falciparum malaria

8.10 additional aspects of management

8.10.1 Treatments not recommended
Several other supportive strategies and interventions have been used in severe malaria
patients in an effort to further reduce the mortality, but very few are supported by
evidence of benefit and many have proved harmful.

Heparin, prostacyclin, desferoxamine, pentoxifylline, low molecular weight dextran,
urea, high-dose corticosteroids, acetylsalicylic acid, deferoxamine, anti-tumour necrosis
factor antibody, cyclosporin, dichloroacetate, adrenaline and hyperimmune serum are not
recommended. In addition, the use of corticosteroids increases the risk of gastrointestinal
bleeding and seizures, and has been associated with prolonged coma resolution times
when compared with placebos (see Annex 8, Sections A8.6 and A8.7).

8.10.2 Fluid therapy

The degree of fluid depletion varies considerably in patients with severe malaria.
As a result, it is not possible to give general recommendations on fluid replacement.
Each patient must be individually assessed and fluid resuscitation based on estimated
deficit. In high-transmission settings, children commonly present with severe anaemia
and hyperventilation (sometimes termed “respiratory distress”) resulting from severe
metabolic acidosis and anaemia; they should be treated by blood transfusion. In general,
children tolerate rapid fluid resuscitation better than adults; they are less likely to develop
pulmonary oedema. In adults, there is a very thin dividing line between over-hydration,
which may produce pulmonary oedema, and under-hydration contributing to shock,
worsening acidosis and renal impairment. Careful and frequent evaluations of the jugular
venous pressure, peripheral perfusion, venous filling, skin turgor and urine output should
be made. Where the nursing facilities permit, a central venous catheter should be inserted
and the central venous pressure measured directly (target 0–5 cm H 2O).

8.10.3 Blood transfusion
Severe malaria is associated with rapid development of anaemia as infected and uninfected
erythrocytes are haemolysed and/or removed from the circulation by the spleen. Ideally
fresh cross-matched blood should be transfused. However, in most settings cross-matched
virus-free blood is in short supply. As with fluid resuscitation, there have not been
enough studies to provide strong evidence-based recommendations on the indications
for transfusion, so the recommendations given here are based on expert opinion. In
high-transmission settings, blood transfusion is generally recommended for children
with a haemoglobin level of < 5 g/100ml (haematocrit < 15%). In low-transmission
settings, a threshold of 20% (haemoglobin 7 g/100 ml) is recommended. However, these
general recommendations still need to be tailored to the individual, as the pathological
consequences of rapid development of anaemia are worse than those of chronic or acute

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