tmd175 slide penatalaksanaan intensif pasien dengan penyakit tropik berat di icu
TRANSCRIPT
PenatalaksananPenatalaksanan intensifintensif pasienpasien dengandenganPenyakitPenyakit TropikTropik BeratBerat
didi ICUICU
Dr .Dr .DadikDadik WahyuWahyu WijayaWijaya SpAnSpAn
DepartemenDepartemen AnestesiologiAnestesiologi & & ReanimasiReanimasi / / InstalasiInstalasiPelayananPelayanan IntensifIntensif (ICU) (ICU)
FKFK--USU / RSUP USU / RSUP H.AdamH.Adam MalikMalik -- MedanMedan
11
IndikasiIndikasi UmumUmum PasienPasien dirawatdirawat didi ICUICU
�� BerdasarkanBerdasarkan PrioritasPrioritas
�� BerdasarkanBerdasarkan DiagnosisDiagnosis
�� BerdasarkanBerdasarkan NilaiNilai--nilainilai Parameter Parameter
HasilHasil LaboratoriumLaboratorium
22
PenyakitPenyakit TropikTropik BeratBerat (yang (yang seringsering
didi ICU :ICU :
�� Tetanus Tetanus BeratBerat (Severe Tetanus)(Severe Tetanus)�� Tetanus Tetanus BeratBerat (Severe Tetanus)(Severe Tetanus)
�� DHF Grade IIIDHF Grade III--IV (DSS)IV (DSS)
�� Malaria Malaria BeratBerat (Severe Malaria)(Severe Malaria)
33
TETANUS BERATTETANUS BERATTETANUS BERATTETANUS BERAT
44
DerajatDerajat KeparahanKeparahan
(Severity Grading(Severity Grading))
�� PhilipsPhilips
�� DakarDakar�� DakarDakar
�� UdwadiaUdwadia GambaranGambaran KlinisKlinis
�� AblettAblett
�� BlectBlect
55
Philips ScorePhilips ScoreWaktu Masuk Skor Selama Perawatan Skor
Masa Inkubasi
> 14 hari
> 10 hari
5 – 10 hari
2 – 5 hari
< 48 jam
1
2
3
4
5
Spasme
Hanya trismus
Kaku seluruh badan
Kejang terbatas
Kejang seluruh badan
Optistotonus
1
2
3
4
5
Imunisasi
Lengkap
< 10 tahun
> 10 tahun
Ibu diimunisasi
Tidak diimunisasi
0
2
4
8
10
Frekuensi Spasme
6 x dalam 12 jam
Dengan rangsangan
Terkadang spontan
Spontan < 3x per 15 menit
Spontan > 3x per 15 menit
1
2
3
4
5
Luka Infeksi Suhu Luka Infeksi
Tidak diketahui
Distal/perifer
Proksimal
Kepala
Badan
1
2
3
4
5
Suhu
36.7 - 37 C
37.1 – 37.7 C
37.8 – 38.2 C
38.3 – 38.8 C
> 38.8 C
1
2
4
8
10
Komplikasi
Tidak ada
Ringan
Tidak membahayakan
Mengancam Nyawa (tidak langsung)
Mengancam nyawa
1
2
4
8
10
Pernafasan
Sedikit berubah
Apnea saat kejang
Kadang apnea setelah kejang
Selalu apnea setelah kejang
Perlu trakeostomi
0
2
4
8
10
Total Skor Derajat Keparahan
< 9 Ringan
9 - 18 Sedang
>18 Berat 66
Grade I (mild)Mild trismus, general spasticity, no respiratory compromise, nospasms, no dysphagia
Grade 2 (moderate)
Ablett Classification of Severity
Grade 2 (moderate)Moderate trismus, rigidity, short spasms, mild dysphagia, moderate respiratory involvement, ventilatory frequency > 30
Grade 3 (severe)Severe trismus, generalized rigidity, prolonged spasms, severe dysphagia, apnoeic spells, pulse > 120, ventilatory frequency > 40
Grade 4 (very severe)Grade 3 with severe autonomic instability
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�� DerajatDerajat KeparahanKeparahan hendaknyahendaknya tidaktidakdipakaidipakai sebagaisebagai pedomanpedoman ““KakuKaku”” untukuntukindikasiindikasi rawatrawat ICUICU
�� IndikasiIndikasi RawatRawat ICU ICU bilamanabilamana caracara--caracarakonvensionalkonvensional yang yang dilakukandilakukan didi ruangruangkonvensionalkonvensional yang yang dilakukandilakukan didi ruangruangperawatanperawatan tidaktidak berhasilberhasil mengatasimengatasi kejangkejang//spasmespasme atauatau pasienpasien mengalamimengalamigangguangangguan pernafasanpernafasan akibatakibat kejangkejang atauatauaspirasiaspirasi, , atauatau telahtelah terjaditerjadi gagalgagal nafasnafasatauatau gangguangangguan sistemsistem lain yang lain yang memerlukanmemerlukan terapiterapi supportifsupportif..
88
Clinical diagnosis of tetanus
Secure Airway
Tracheostomy
Benzodiazepines2
MidazolamDiazepam
Antitoxin2
HIG im/itEquine antitoxin im
Antibiotics2
MetronidazoleManage autonomic dysfunction
Flow diagram showing the management of tetanus.
1—limited evidence; 2—some evidence; 3—good evidence.
Magnesium2
Inotropes1
Benzodiazepines2
Bupivacaine2
Morphine2
Clonidine2
ConsiderDVT Prophylaxis1
Control Muscle Spasms
Benzodiazepines2 Dantrolene1
NDNMBA’s1 Baclofen2
Magnesium2
Full primary course of immunisation1
99
Therapeutic ManagementTherapeutic Management
ImmunizationImmunization
Wound debridementWound debridement
AntibioticsAntibioticsAntibioticsAntibiotics
Control muscle spasmControl muscle spasm
Control Autonomic DisturbanceControl Autonomic Disturbance
Other supportive therapyOther supportive therapy
1010
MANAGEMENTMANAGEMENT
1. 1. Neutralize toxin outside of CNSNeutralize toxin outside of CNS
-- Human Tetanus Immune Globulin Human Tetanus Immune Globulin
HTIGHTIG)) 150 units/kg IM or 5,000150 units/kg IM or 5,000--HTIGHTIG)) 150 units/kg IM or 5,000150 units/kg IM or 5,000--
10,000 units IV10,000 units IV
-- ATS ATS 500 UI/kgBB intramuscular.500 UI/kgBB intramuscular.
1111
22. . Prevent further toxin releasePrevent further toxin release
-- Early surgical debridement of Early surgical debridement of
woundswounds
-- Antibiotics : Antibiotics : MetronidazoleMetronidazole 500mg500mg
MANAGEMENTMANAGEMENT
-- Antibiotics : Antibiotics : MetronidazoleMetronidazole 500mg500mg
8 hourly and Penicillin G 1 MU 68 hourly and Penicillin G 1 MU 6--88
hourly. hourly.
Heavily contaminated wound mayHeavily contaminated wound may
need additional antibiotics.need additional antibiotics.1212
MANAGEMENTMANAGEMENT
3.3. Minimize the effects of toxin already Minimize the effects of toxin already
exists in CNSexists in CNS
-- Control rigidity and spasmControl rigidity and spasm-- Control rigidity and spasmControl rigidity and spasm
-- Respiratory support as necessary Respiratory support as necessary
-- Control of autonomic dysfunction.Control of autonomic dysfunction.
1313
Drug used to control spasm and Drug used to control spasm and autonomic disturbanceautonomic disturbance
BenzodiazepineBenzodiazepine
MorphineMorphine
Muscle relaxant: Muscle relaxant: vecuroniumvecuronium, , rocuroniumrocuronium, , Muscle relaxant: Muscle relaxant: vecuroniumvecuronium, , rocuroniumrocuronium, , pancuroniumpancuronium
Magnesium sulfateMagnesium sulfate
DantrolenDantrolen
BaclofenBaclofen
BupivacainBupivacain, atropine,, atropine,1414
BenzodiazepineBenzodiazepine
Common used as anticonvulsant in Common used as anticonvulsant in tetanus.tetanus.
Has sedative effectHas sedative effect
Dose of Diazepam vary 100Dose of Diazepam vary 100--400 mg/24 h 400 mg/24 h Dose of Diazepam vary 100Dose of Diazepam vary 100--400 mg/24 h 400 mg/24 h max until 2400mg/24 hmax until 2400mg/24 h
Preservative used can cause acidosis in Preservative used can cause acidosis in large doselarge dose
No/little effect on autonomic disturbanceNo/little effect on autonomic disturbance
1515
Magnesium SulfateMagnesium Sulfate
-- Pre synaptic neuromuscular blockerPre synaptic neuromuscular blocker
-- Blocks catecholamine release from nerve and Blocks catecholamine release from nerve and
adrenal medullaadrenal medulla
-- Reduce receptor responsiveness to release Reduce receptor responsiveness to release
catecholaminescatecholamines
-- It antagonizes calcium in myocardium and at It antagonizes calcium in myocardium and at
the neuromuscular junctionthe neuromuscular junction
-- Inhibits parathyroid hormone releaseInhibits parathyroid hormone release
anticonvulsant-vasodilator1616
DoseDose
Adult : a loading dose of 5 gram over 20 Adult : a loading dose of 5 gram over 20 minutes IV followed by 1g hourly minutes IV followed by 1g hourly increasing to 2.5 gram hourly when increasing to 2.5 gram hourly when necessary. Titrate to symptomsnecessary. Titrate to symptomsnecessary. Titrate to symptomsnecessary. Titrate to symptoms
Pediatrics : 100mg /kg/24 hours, can be Pediatrics : 100mg /kg/24 hours, can be increased when necessary. Titrate to increased when necessary. Titrate to symptomssymptoms
Sometimes MgSO4 is inadequate to be used alone, combination with benzodiazepine is also mandatory
1717
Monitoring of possible side effectsMonitoring of possible side effects
-- Patellar reflexPatellar reflexDiminished at the level of Magnesium >4 Diminished at the level of Magnesium >4 mmolmmol/L/L
-- Respiratory depression because of muscle Respiratory depression because of muscle paralysis (>Mg 6 paralysis (>Mg 6 mmolmmol/L)/L)
-- BradyarrhythmiaBradyarrhythmia, hypotension, hypotension-- BradyarrhythmiaBradyarrhythmia, hypotension, hypotension-- Urine output Urine output
Low output causes drug accumulationLow output causes drug accumulation-- Blood Calcium level, blood Magnesium level Blood Calcium level, blood Magnesium level
should be checked regularlyshould be checked regularly-- Overdose may cause sedation and anesthesia.Overdose may cause sedation and anesthesia.
Day 4 Day 6
Magnesium can be a prospective
alternative for treatment of tetanus,
especially when there are mass
casualties since it reduces the need for casualties since it reduces the need for
mechanical ventilation, however,
meticulous ICU monitoring is needed
with ready for use ventilator.
Gempa Yogyakarta
Others Drugs & RegimentOthers Drugs & Regiment
ObatObat pelemaspelemas otototot (muscle relaxant) (muscle relaxant) intermittent intermittent bilabila diperlukandiperlukan. .
BaclofenBaclofen (beta (beta –– [4[4--chlorophenyl] gamma chlorophenyl] gamma amino butyric acid) amino butyric acid) sebagaisebagai PP--GABA GABA amino butyric acid) amino butyric acid) sebagaisebagai PP--GABA GABA receptor agonist, receptor agonist, menghambatmenghambat pelepasanpelepasanasetilkolinasetilkolin presinapspresinaps diotakdiotak, , diberikandiberikanintrathekalintrathekal
PropofolPropofol (1,6(1,6--diisopropyl phenol) diisopropyl phenol) dapatdapatdipakaidipakai sebagaisebagai sedasisedasi, , dengandengan dosisdosistritrasitritrasi. .
2222
Others Drugs & RegimentOthers Drugs & Regiment
PenghambatPenghambat beta :beta :Propanolol,LabetololPropanolol,Labetolol, , EsmololEsmolol
Agonist alfaAgonist alfa--2 : 2 : ClonidineClonidine
DexmedetomidineDexmedetomidineDexmedetomidineDexmedetomidine
OpioidOpioid kombinasikombinasi dengandengan sedative :sedative :Morphine + Morphine + midazolammidazolam atauatau diazepam diazepam
Sodium Sodium valproatevalproate
ACE Inhibitor ACE Inhibitor 2323
TerapiTerapi supportifsupportif lainnyalainnya
�� Terapi fisik (fisioterapi) karena pasien Terapi fisik (fisioterapi) karena pasien imobilisasi cukup lama. imobilisasi cukup lama.
�� VentilasiVentilasi mekanikmekanik
MANAGEMENTMANAGEMENT
�� VentilasiVentilasi mekanikmekanik
�� Metabolik : Nutrisi enteral , ditambah Metabolik : Nutrisi enteral , ditambah parenteral bila perlu.parenteral bila perlu.
�� Penggunaan inotropik dan atau Penggunaan inotropik dan atau vasopresorvasopresor
�� AntikoagulanAntikoagulan2424
3 major complications cause death3 major complications cause death
VentilatoryVentilatory restriction leading to respiratory restriction leading to respiratory VentilatoryVentilatory restriction leading to respiratory restriction leading to respiratory complication and sepsiscomplication and sepsis
Autonomic disturbanceAutonomic disturbance
Stress ulcer/gastric bleedingStress ulcer/gastric bleeding
2525
DHF GR IIIDHF GR III--IV (DSS)IV (DSS)DHF GR IIIDHF GR III--IV (DSS)IV (DSS)
2626
DF DHF (Grades)
I II III IV
FebrilePhase(3-7 days)
Afebrile Phase(Critical Stage)(Critical Stage)
ConvalescentPhase
If Appropriate Treatment not provided, there is a high rist death
RECOVERY
Grading the Severity of Dengue Infection
DF/DHF Grade* Symptoms Laboratory
DF
DHF
DHF
I
II
Fever with two or more of the following signs : headache, retro –orbital pain, myalgia, arthalgia
Above signs plus positive Tourniquet test
Above signs plus spontaneous
Leukopenia, Occasionally, Thrombocytopenia, may be present, no evidence of plasma loss
Thrombocytopenia, < 100,000, Hct rise ≥ 20 %
Thrombocytopenia, < 100,000, DHF
DHF
DHF
II
III
IV
Above signs plus spontaneous bleeding
Above signs plus circulatory failure (weak pulse, hypotension,restlessness)
Profound shock with undetectable blood presure and pulse
Thrombocytopenia, < 100,000, Hct rise ≥ 20 %
Thrombocytopenia, < 100,000, Hct rise ≥ 20 %
Thrombocytopenia, < 100,000, Hct rise ≥ 20 %
* DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS)
Clinical Manifestation DSSClinical Manifestation DSS
Increase of Vascular permeability : Increase of Vascular permeability : HaemoconcentrationHaemoconcentration, , HypoalbuminemiHypoalbuminemi, , HypoproteinemiaHypoproteinemia, Shock, Pleural , Shock, Pleural effusioneffusioneffusioneffusion
ThrombopathyThrombopathy
CoagulopathyCoagulopathyHemorrhage
2929
PENATALAKSANAAN
Afebrile phase
Duration two daysafter febrile stage
Manifestations
In addition to the manifestations ofDHF Grade II :– Circulatory failurse manifested by
rapid and weak pulse, narrowingof pulse pressure (20 mmHg orless) or Hypotension with thepresence of cold clammy skinand restlessness
– Capillary relief time more thantwo seconds
Management
– Check haematocrits/platelet
– Initiate IV Therapy (5% D/NSS) 10 ml/kg/h– Check Haematocrit , vital signs, urine output every
hour.– If patient improves IV fluids should be reduced every
hour from 10 to 6 and from 6 to 3 ml/kg/h which can bemaintained up to 24 to 48 hours.
– If patients has already received one hour treatment of20 ml/kg/hr of IV fluids and vital signs are not stablecheck haematocrit again andtwo seconds
Profound shock with undetectablepulse and blood pressure.
check haematocrit again and– If haematocrit is increasing change IV fluid to colloidal
solution preferably Dextran or plasma at 10 ml/kg/hevery hr.
– If haematocrit is increasing from initial value give freshwhole blood transfusion, 10 ml/kg/h and continue fluidtherapy at 10 ml/kg/h and reducing it stepwise bringdown the volume to 3 ml/kg/h and maintain it up to 24 –48 hours.
– Initial IV therapy (5% D/NSS) 20 ml/kg as a bolus oneor two times
– Oxygen therapy should be given to all patients.– In case of continued shock colloidal fluids (Dextran or
Plasma) should be given at 10 – 20 ml/kg/hr.
Afebrile phase
Con Phase
Manifestation
Profound shock with undetectablePulse and blood pressure
Manifestation
Management
- If shock still persists and the haemotocrit level continues declining give fresh whole blood 10 ml/kg as a bolus
- Vital signs should be monitored every 30 –60 minutes
- In case of severe bleeding gives fresh whole blood 20 ml/kg as a bolus
- Give platelet rich plasma transfusion exceptionally when platelet counts are below 5.000 – 10.000 / mm3
- After blood transfusioncontinues fluid therapy at 10 ml/kg/h and reduce it stepwise to bring it down to 3 ml/kg/h and maintain in for 24 – 48 hrs
ManagementCon Phase
Duration 2 – 3 daysAfter recovery from critical/shock stage
Manifestation
- 6 – 12 hours after critical/shock stage some symptoms of respiratory distress (pleural effusion or arcites)
- 2-3 days after critical stage , strong pulse, normal blood pressure.
- Improved general condition/return of appetite.
- Good urine output- Stable haematocrit- Pletelet count > 50.000 per mm3
- Patient could bedischarged from hospital 2 – 3 days after critical stage
- Bradycardia/arrhytmia- Asthenia and depression (few
weeks) in adult
Management
- Rest for 1 – 2 days- Normal diet- No need for medication
Fluid Therapy in DSSFluid Therapy in DSS
The policy of initial fluid therapy in DSS The policy of initial fluid therapy in DSS
according to the according to the Department of Health Department of Health
and WHO until 2003 :and WHO until 2003 :
Crystalloid (Lactate Ringer), followed Crystalloid (Lactate Ringer), followed
with colloid (with colloid (DextranDextran) if not responded) if not responded
3232
Department of HealthDepartment of HealthIndonesian Intensive Care AssociationIndonesian Intensive Care Association
Indonesian Anesthesiology AssIndonesian Anesthesiology AssIndonesian Indonesian PaedPaed. Ass (2004). Ass (2004)
Review on the management of DHFReview on the management of DHFReview on the management of DHFReview on the management of DHF
Change the protocolChange the protocol
Include colloid MMWInclude colloid MMW--6% HES as alternative as 6% HES as alternative as
initial fluid resuscitation in DSSinitial fluid resuscitation in DSS
3333
Lactated Ringer's
Volume Replacement Therapy Volume Replacement Therapy
ColloidsCrystalloidsCrystalloids
HES
solutions
Dextran
solutions
Gelatin
solutionsAlbuminPPL
Lactated Ringer's
Normal Saline
3434
Crystalloid (RL, RA, Crystalloid (RL, RA, NaCLNaCL))
Distributed to the interstitial spaceDistributed to the interstitial space
Very short period in the intravascular spaceVery short period in the intravascular spaceVery short period in the intravascular spaceVery short period in the intravascular space
Need more fluid to maintain intravascular Need more fluid to maintain intravascular
volume volume �������� risk for interstitial edema / risk for interstitial edema /
pulmonary edemapulmonary edema
3535
–– HES: ( MW 100.000HES: ( MW 100.000--300.000 300.000 kDkD ): Sealing ): Sealing
effect +, effect +, good intravascular volume effect, good intravascular volume effect,
longer duration in the intravascular space, longer duration in the intravascular space, ↑↑↑↑↑↑↑↑
ColloidColloid
DO2, DO2, ↑↑↑↑↑↑↑↑VO2VO2
–– DextranDextran : : LMW colloid (40.000LMW colloid (40.000--70.000 70.000 kDkD))
with good preservation volume effect, with good preservation volume effect, no no
sealing effectsealing effect, increase anaphylactic , increase anaphylactic
reactionreaction
3636
HydroxyethylHydroxyethyl Starch (HES)Starch (HES)
-- Effective Effective and safe plasma substituteand safe plasma substitute
-- HES HES �������� broad range of MW, from very small until broad range of MW, from very small until
several hundred thousand Daltonseveral hundred thousand Dalton
-- Classification of HES (by in vitro) according to Classification of HES (by in vitro) according to -- Classification of HES (by in vitro) according to Classification of HES (by in vitro) according to MW:MW:-- HIGH MOLECULAR WEIGHT (HMW) HIGH MOLECULAR WEIGHT (HMW) →→ 450 K 450 K DaDa
-- MEDIUM MOLECULAR WEIGHT (MMW) MEDIUM MOLECULAR WEIGHT (MMW) →→ 200 K 200 K DaDa
-- LOW MOLECULAR WEIGHT (LMW) LOW MOLECULAR WEIGHT (LMW) →→ 70 K 70 K DaDa
Sealing effectSealing effect : HES with 100: HES with 100––300.000 D MW300.000 D MW
Effect Effect of HES on Blood Coagulationof HES on Blood Coagulation
HMWHMW--HES HES ��������more effect on blood coagulation more effect on blood coagulation
((vWFvWF, factor VIII), factor VIII)
LMW (HES 70/0.5/4)/LMW (HES 70/0.5/4)/MMW(HES 200/0.5/6MMW(HES 200/0.5/6) ) �������� did did LMW (HES 70/0.5/4)/LMW (HES 70/0.5/4)/MMW(HES 200/0.5/6MMW(HES 200/0.5/6) ) �������� did did
not affect on blood coagulationnot affect on blood coagulation
Possible Possible dilutionaldilutional coagulation effect : PT, coagulation effect : PT, aPTTaPTT
(significant prolongation after HMW(significant prolongation after HMW--HES 480)HES 480)
Fluid Resuscitation in DSSFluid Resuscitation in DSS
Primary importance in the management Primary importance in the management
of of hypoperfusionhypoperfusion statestate
Goal of therapyGoal of therapyGoal of therapyGoal of therapy
↑↑ Tissue DOTissue DO22
↑↑ Blood PressureBlood Pressure
↑↑ VOVO22
Reversing Lactic AcidosisReversing Lactic Acidosis
Colloid Colloid MMW MMW
3939
Study on DSS using colloid (HES ) Study on DSS using colloid (HES ) as initial fluid resuscitationas initial fluid resuscitation
Tatty E. Tatty E. SetiatiSetiati Different
RESULTTatty E. Tatty E. SetiatiSetiati
(2000)(2000)
HerminiaHerminia L. L. CifraCifra
(2001(2001) H) H
RESULT
Different
method of
study
4040
RL group Colloid group (HAES Steril 6%)
Duration of
shock ( Hour)
7.9+/- 2.6 2.3 +/- 2
Ventilators days 8 +/- 1.1 4.0 +/- 0.71
Pleural effusion 30M2/Mod7/S21
_
ALI /PaO2/FiO2=200-250 4 1
ARDSPaO2/FiO2 < 200
6 2
ConclusionConclusion
Evidenced showed that endothelial dysfunction Evidenced showed that endothelial dysfunction
lead to vascular leakage and lead to vascular leakage and hemostatichemostatic
disturbances occurred in DSSdisturbances occurred in DSS
MMW which has a sealing effect could MMW which has a sealing effect could MMW which has a sealing effect could MMW which has a sealing effect could
minimizing vascular leakage, good preservation minimizing vascular leakage, good preservation
volume effect, and lowering mortalityvolume effect, and lowering mortality
MMW HES can be used as alternative for initial MMW HES can be used as alternative for initial
fluid resuscitation in DSSfluid resuscitation in DSSS S
4242
What not to do in DSS
Do not give Aspirin or Ibuprofen for treatment of fever.
Avoid giving intravenous therapy before there is evidence of haemorrhage and bleeding.
Avoid giving blood transfusion unless indicated, reduction in haematocrit or severe bleeding.in haematocrit or severe bleeding.
Avoid giving steroids. They do not show any benefit.
Do not use antibiotics
Do not change the speed of fluid rapidly, i.e. avoid rapidly increasing or rapidly slowing the speed of fluids.
Insertion of nasogastric tube to determine concealed
bleeding or to stop bleeding (by cold lavage) is not
recommended since it is hazardous.
4343
Signs of Recovery
Stable pulse, blood pressure and breathing rate
Normal temperature
No evidence of external or internal bleeding
Return of appetiteReturn of appetite
No vomiting
Good urinary output
Stable haematocrit
Convalescent confluent petechiae rash
4444
SEVERE MALARIASEVERE MALARIASEVERE MALARIASEVERE MALARIA
4545
What is severe malaria?
Severe malaria is the serious or life-threatening
form of falciparum malaria which needs active
appropriate patient management.
According to WHO criteria in 1990, severe malaria
patients have asexual forms of Plasmodium
falciparum on a blood film and may have any one
or more of the following manifestations and
complications :
4646
1. Cerebral malaria (unrousable coma not
attributable to any other cause)
2. Severe normocytic anemia (haematocrit <15% or hemoglobin <5 g/dl)
3. Acute renal failure (urine output <400 ml/24 3. Acute renal failure (urine output <400 ml/24 hours in adults or 12 ml/kg/24 hours in children, failing to improve after redydration and
serum creatinine >265 mmol/l (3 mg/dl))
4. Pulmonary edema or adult respiratory distress syndrome (ARDS)
4747
5. Hypoglyceamia (whole blood glucose <2.2
mmol or l40 mg/dl)
6. Circulatory collapse, shock: hypotension
(systolic blood pressure <50mmHg in children
aged 1-5 years or <70 mmHg in adults), with
cold clammy skin or core-skin temperature
difference >10 °C)
7. Spontaneous bleeding/disseminated
intravascular coagulation (DIC)
8. Repeated generalized convulsions
9. Acidaemia (arterial pH <7.25) or acidosis
(plasma bicarbonate <15 mmol/l)
10. Macroscopic haemoglobinuria
11. Post-mortem confirmation of diagnosis4848
WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER WHO MULTICENTER STUDY ON SEVERE MALARIA IN UNDER FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 FIVES IN 10 AFRICAN COUNTRIES (1230 CASES, 1999 –– 2000)2000)
PREVALENCE OF SIGNS AND SYMPTOMSPREVALENCE OF SIGNS AND SYMPTOMS
SIGNS AND SYMPOMS NUMBER %
SEVERE ANEMIA 666 54.1SEVERE ANEMIA 666 54.1
PROSTRATION 371 30.2
CONVULSIONS 279 22.7
CEREBRAL MALARIA 218 17.7
HYPOGLYCEMIA 162 13.2
HYPOGLOBINURIA 41 3.3
JAUNDICE 21 1.7
RESPIRATORY DISTRESS 12 1.0
DISSEMINATED INTRAVASCULAR 1 0.08
COAGULATION
4949
Different clinical manifestation between adults and children with severe malaria
Adult Children
Cough Uncommon early symptom Common early symptom
Convulsions Indicate cerebral involvement May indicate cerebral
involvement or hypoglycemia,
but may be non – specific
consequence of fever
Duration of symptoms Commonly several days Usually 1 – 2 days onlybefore features of severebefore features of severedisease develop
Jaundice Common Uncommon
Time from start of Usually quinine 2 – 4 days Usually 1 – 2 daystreatment to resolutionof coma in cerebral malaria
Hypoglycemia Relatively uncommon CommonUsually quinine-induced (especially in pregnancy)
Pulmonary edema Common RareRenal failure Common RareNeurological sequelae Uncommon Occur in about 10% of cases
after cerebral malaria
ManagementManagement
· Parenteral antimalarials.
· IV fluid administration.
· Vital signs monitoring every 4 hours.
· Blood check up for malaria parasite every day until disappearance of parasitemia.day until disappearance of parasitemia.
· Monitoring clinical signs and symptoms of severe malaria that may occur later.
· Record conscious level every 4 hours and urine output every 8 hours.
5151
Antimalarial drug doses in severe malariaHospital
ICU
Health Clinic :
No Intravenous
Infusion Possible
Rural health clinic :
No injection facilities
Chloroquine-resistant
P falcipanum
Quinine
Quinine dihydrochloride
7 mg salt/kg infused over
30 min followed by
Immediately 10 mg/kg
Over 4 h: or 20 mg salt/kg
Infused over 4 h
Maintenance dose: 10 mg
Salt/kg infused over 2-8 h
Quinine dihydrochloride
20 mg salt/kg diluted 1 : 2 with sterile
water given by split injection into both
anterior thighs. Maintenance dose : 10
mg/kg 8 hourly
Artesunate rectocap :
10 mg/kg daily
Artemisinin suppository
20 mg/kg at 0 and 4 h
Then daily
Chloroquine – sensitive
P falcipanum
Salt/kg infused over 2-8 h
At 8 h intervals
Arteminisim derivative :
a) Artemether 3.2 mg/kg
Stat By im injection
Followed by 1.6 mg/kg
Daily
a) Artesunate 2.4 mg/kg stat
By iv injection followed by 1.2
mg/kg daily
Chloroquine
Chloroquine 10 mg base/kg
Infused iv at constant rate over 8 hr
followed by 15 mg base/kg over 24 hr
As for Hospital ICU :
Artesunate can also be
Given by im injection
Chloroquine 3.5 mg
Base kg 6-hourly or 2.5 mg
base/kg 4 hourly by im or sc injection.
Total dose 25 mg base/kg
Chloroquine 10 mg/kg daily
Or nasogastric chloroquine as for
oral regimen
Poor prognostic features in severe malaria
Clinical findings
� Deep Coma� Deep Coma
� Repeated convulsions
� Respiratory distress (rapid, deep, laboured, stertorous,
breathing often with intercostals recession)
� Significant bleeding
Laboratory findings
Biochemistry
� Hypoglycemia < 2.2 mmol/l� Hyperlactatemia > 5 mmol/l� Acidosis arterial pH<7.3 venous plasma HCO3 < 15 mmol/l� Serum creatitine >265 µmol/l� Total bilirubin > 50 µmol/l� Liver enzymes SGOT (AST) x 3 upper limit of normal
SGPT (ALT) x 3 upper limit of normal5 – Nucleotidase
� Muscle enzymes CPKMyoglobin
� Urate > 600 µmol/l� Urate > 600 µmol/l
Hematology
� Leucocytosis >12.999/µl� Severe anemia PCV < 15 %� Coagulopathy Platelet < 50.000/µl
PT prolonged > 3 sProlonged PPTFibrinogen <200 mg/dl
Parasitology
� Hyperparasitemia > 100.000/µl - increased mortality> 500.00/µl - high mortality
� >20% of parasites are pigment – containing trophozoites and schizonts� >5% of neutrophils contain visible malaria pigment
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