The fluid management of adults with severe malaria |
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Authors: | Josh Hanson Nicholas M Anstey David Bihari Nicholas J White Nicholas P Day Arjen M Dondorp |
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Affiliation: | .Menzies School of Health Research, Royal Darwin Hospital, Rocklands Drive, Tiwi, NT 0810 Australia ;.Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400 Thailand ;.Prince of Wales Hospital, Barker Street, Randwick, NSW 2031 Australia ;.Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford Roosevelt Drive, Oxford, OX3 7FZ UK |
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Abstract: | Fluid resuscitation has long been considered a key intervention in the treatment of adults with severe falciparum malaria. Profound hypovolemia is common in these patients and has the potential to exacerbate the acidosis and acute kidney injury that are independent predictors of death. However, new microvascular imaging techniques have shown that disease severity correlates more strongly with obstruction of the microcirculation by parasitized erythrocytes - a process termed sequestration. Fluid loading has little effect on sequestration and increases the risk of complications, particularly pulmonary edema, a condition that can develop suddenly and unpredictably and that is frequently fatal in this population. Accordingly, even if a patient is clinically hypovolemic, if there is an adequate blood pressure and urine output, there may be little advantage in infusing intravenous fluid beyond a maintenance rate of 1 to 2 mL/kg per hour. The optimal agent for fluid resuscitation remains uncertain; significant anemia requires blood transfusion, but colloid solutions may be associated with harm and should be avoided. The preferred crystalloid is unclear, although the use of balanced solutions requires investigation. There are fewer data to guide the fluid management of severe vivax and knowlesi malaria, although a similar conservative strategy would appear prudent.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0642-6) contains supplementary material, which is available to authorized users. |
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