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Management of severe falciparum malaria Dr SK Mishra,MD Ispat General Hospit al, Rourkela 769005 India

Management of severe falciparum malaria Dr SK Mishra,MD Ispat General Hospit al, Rourkela 769005 India.

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Management of severe falciparum malaria Dr SK Mishra,MD Ispat General Hospit al, Rourkela 769005 India

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  1. Management ofsevere falciparum malariaDr SK Mishra,MDIspat General Hospital, Rourkela 769005India

  2. Falciparum malaria is a potentially fatal diseaseSuccessful treatment completely cures without disabilityEarly diagnosis and prompt treatment prevents fatal complications 2

  3. Severe malaria1. Cerebral malaria2. Acute renal failure 3. ARDS4. Severe anaemia (Hb < 5g%)5. DIC6. Haemoglobinuria7. Hypotension, Shock8. Hyperparasitemia9. Repeated seizures10. Hyperpyrexia11. Haemolysis (Sr bil. >3 mg%)

  4. Diagnosis of malaria1. History and clinical features * locality , travel history * fever * spleno-hepatomegaly * presence of complications 2. Laboratory diagnosis 3

  5. * Drug history* Anti malarials* Blood transfusionHistory of - haemoglobinopathy - diabetes - alcoholism/ jaundice 4

  6. Specifically ask / look for - fever with duration - headache - vomiting, diarrhoea - urine output and colour - cough / dyspnoea/ bleeding - altered sensorium / seizures - pregnancy 5

  7. Clinical examination Pallor, icterus bleeding signs early signs of pulm oedema consolidation arrhythmia hepatosplenomegaly uterus 6

  8. CNS ExaminationSensorium /coma score- Glasgow coma score- Blantyre coma score- decerebrationPupils, Fundus examinationNeck stiffnessPlantar reflex 7

  9. Laboratory diagnosis • Microscopy • Immunological tests • Antigen capture tests • Antibody detection tests • QBC test • DNA probe • PCR 8

  10. Microscopygold standard for diagnosisthick smear: rapid diagnosisthin : species identificationother advantage- platelets, anaemia, toxic pictureIf negative : repeat blood test 6 hourly for 6 times9

  11. Why parasites are not detected at times in peripheral smear ?a. sequestration in deep vascular bedb. partially treated patientsc. prophylactic antimalarial treatmentd. inexperienced microscopiste. poor quality staining 10

  12. Antigen capture tests* Pf-ICT test * Parasight-F test/ Malacheck etcPrinciple: dipstick antigen capture assay employs a monoclonal antibody detecting the Pf.HRP-2 antigen in the bloodRapid, simple, sensitive testSpecies specificity 11

  13. Antibody detection test- RIA - ELISAantibody persists for a long time so not helpful in acute infection12

  14. QBC testSpinning blood in a specialised capillary tubes in which parasite DNA is stained with acridine orange.Detected by ultraviolet microscopeSensitive and specific (?) inExperienced hands 13

  15. PCR testSensitiveCan identify different speciesTakes 48- 72 hoursExpensiveAvailable in selected places onlyDNA Probes 14

  16. Cerebral malariaComa scoringExclude other causes of coma1. ABC of coma care2. Prompt institution of antimalarials3. Treatment of hyperpyrexia4. Management of other complications5. Treatment of associated infections 17

  17. Antimalarial therapyParenteral therapy is a must asrapid parasitecidal action is warrantedMainstay of therapy is Quinine- Loading dose or not ?- IV is the route of choice - Donot reduce the dose in first 48 hours of quinine therapy- 20% renal and 80% hepatic clearance 18

  18. Quinine therapy10 mg/ kg body weight over 4 hours every 8 hourly in DNS or dextrose.If therapy has to continue beyond 48 hours reduce dose to 2/3rd. T 1/2 healthy subjects - 11 hours uncomplicated patients 16 hours cerebral malaria - 18 hours19

  19. Side effects:Minor: cinchonism, tinnitus deafness, vertigo, vomitingdoes not require stoppage of quinine treatment.Severe: hypoglycemia, DIC,haemolysis, arrhythmia, thrombocytopenia etc. These complications are rare.20

  20. Artemisinine compoundsRapid schizonticidal drugArteether (E-mal) inj150 mg deep im od x 3 daysArtemether (Larither)Inj 80 mg im bid x 3 daysor Inj. 80 mg bid first day then od x 4 daysArtesunate (falcigo)Unstable, to be prepared before administration 2.4 mg/kg first dosem then 1.2 mg 12 hr then daily for 3-4 days 21

  21. COMMON ERRORS INMANAGEMENT OFSEVERE MALARIA1.Failure to diagnose associated complications such as bacterial infections, eclampsia, Gram negative septicemia etc.2. Missed hypoglycaemia3. Misjudgement of severity 22

  22. 4.Errors of fluid and electrolytic replacement5.Errors in anti-malarial chemotherapy6. Delay in starting treatment Unjustified withholding of antimalarial drug for the fear of toxicity e.g. Quinine in pregnant women, in hypoglycaemia-Inadequate dosage administration-Failure to control the rate of IV infusion 23

  23. 7. Delay in considering obstetrics intervention pregnant women suffering from malaria8.Missed / late diagnosis of ARDS, acute pulmonary oedema 9 Use of inappropriate ancillary therapies e.g. steroids, .10. Delay in starting dialysis 24

  24. This lecture is prepared exclusively for Supercourse

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