Samuel M Baso

SMF IPD RSU Jayapura

 Criteria of Severe Malaria
Definition
In a patient with P. falciparum/vivax asexual parasitaemia and no other
obvious cause of symptoms, the presence of one or more of the following
clinical or laboratory features classifies the patient as suffering from severe
malaria
Clinical feature :
- impaired consciousness or unrousable coma
prostration, i.e. generalized weakness so that the patient is unable walk
or sit up without assistance
failure to feed
multiple convulsions more than two episodes in 24 h
deep breathing, respiratory distress (acidotic breathing)
circulatory collapse or shock, systolic blood pressure < 70 mm Hg in
adults and < 50 mm Hg in children
clinical jaundice plus evidence of other vital organ dysfunction
haemoglobinuria
abnormal spontaneous bleeding
pulmonary oedema (radiological)

Laboratory findings :
hypoglycaemia (blood glucose < 2.2 mmol/l or < 40 mg/dl)
metabolic acidosis (plasma bicarbonate < 15 mmol/l)
severe normocytic anaemia (Hb < 5 g/dl, packed cell volume < 15%)
haemoglobinuria
hyperparasitaemia (> 2%/100 000/l in low intensity transmission areas or >5%
or 250 000/l in areas of high stable malaria transmission intensity)
hyperlactataemia (lactate > 5 mmol/l)
renal impairment (serum creatinine > 265 mol/l).
Risk, Injury, Failure, Loss of Kidney Function, End-stage Kidney Disease classification

Class GFR criteria Urinary output criteria

Risk Serum creatinine 1.5 or GFR decrease > 25% < 0.5 ml/kg/hour 6 hours

Injury Serum creatinine 2 or GFR decrease > 50% < 0.5 ml/kg/hour 12 hours

Failure Serum creatinine 3, GFR decrease > 75% <0.3 ml/kg/hour x 24 hours
or serum creatinine 4 mg/dl with an or anuria x 12 hours
acute rise > 0.5 mg/dl

Loss Persistent acute renal failure = complete

loss of kidney function> 4 weeks

End-stage kidney disease End-stage kidney disease > 3 months

 Pathofisology of severe malaria

Sequestration is removal of infected RBCs from

the peripheral circulation by binding to the vascular
endothelium often accompanied by unifected erythrocytes
Cytoadherence
Rosetting
Accumulation of parasitized cells in the
local postcapilary microvasculature and
block the flow
Severe Malaria is determined by factors from both the
parasite and human host
Host immune system and antimalarial agent
Patofisologi
 MICROVASCULAR
OBSTRUCTION

FLOW
UNINFECTED
RBC
C d
RB itize

knob
ras
Pa

PfEMP1, 2, 3
PfHRP1 or ROSETTING
KAHRP ADHESION

CYTOADHESION ENDOTHELIAL SURFACE

 Differential diagnosis

Infeksi virus : DHF, influenza, ensefalitis, HIV

Demam tipoid, Bronkopneumonia
Hepatitis
Sepsis
Meningitis atau meningoensefalitis
Acute on CKD
TB
Koma hipoglikemia karena OHA
 Ada beberapa kekhususan
Pada Papua :

1. 100 % resisten klorokuim

2. SP resistensi juga100%
3. Quinine efektifitasnya ?
4. Artesdiaquine efektifitasnya?
5. 60-70% penderita falsiparum

Kesepakatan Nasional :
Untuk Papua
AZT (Artemisinin + DHP)
Kina kombinasi dgn doksisiklin
atau klindamisin
Primaquin 1x3 tab utk Pf dan
1x2 selama 8 hr (1x1 sel 14 hr)
Management of Severe Malaria
Termasuk kedaruratan medis
Kalau fasilitas ada dirawat di
ruang intensif
Resusitasi : A B C D
Suportif : - Cairan
- TPN atau MLP
- antipiretic
- H2 blocker atau PPI
- Antiemetic
Potent antimalaria :
Artesunat IV atau Quinine drip
Komplikasi :
Tergantung komplikasi yang
terjadi
 Rehidrasi dgn cairan kristaloid
Kalau gagal bisa dgn koloid
Kalau memakai Quinine Dx 10%
Berikan oksigen
Balance cairan
Atasi gangguan elektrolit
Kalau kejang diberikan
diazepam iv
Hiperpireksia dgn parasetamol
infus
Muntah2 dgn ondansentron,
PPI atau H2 bloker
 Prinsip pengobatan Malaria :

Pengobatan dengan kombinasi

Clerance of parazite cepat
Tidak relaps (28 hari)
Efikasi >98 %
Eradikasi Malaria
Bebas Malaria 2030???
Quality of life

Obat antimalaria :
Prinsip Kombinasi
Artesunat/Artemisin
Quinine
Primaquin
Doksisiklin
Klindamisin
Mefloquin
Halofantrin
Atovaquone-proguanil
 TREATMENT OF SEVERE MALARIA

Severe malaria is a medical emergency. After rapid clinical assessment and

confirmation of the diagnosis, full doses of parenteral antimalarial treatment
should be started without delay with which ever effective antimalarial is first
available.
For adults, artesunate IV or IM:
quinine is an acceptable alternative if parenteral artesunate is not available.
For children (especially in the malaria endemic areas of Africa) the following
antimalarial medicines are recommended as there is insufficient evidence to
recommend any of these antimalarial medicines over another:
quinine (IV infusion or divided IM injection);
artemether IM (should only be used if none of the alternatives are available as its
absorption may be erratic).
Give parenteral antimalarials in the treatment of severe malaria for a minimum of 24 H
, once started (irrespective of the patients ability to tolerate oral medication earlier)
and, thereafter, complete treatment by giving a complete course of:
an ACT;
artesunate plus clindamycin or doxycycline;
quinine plus clindamycin or doxycycline.
If complete treatment of severe malaria is not possible, patients should be given pre-
referral treatment and referred immediately to an appropriate facility for further
treatment. The following are options for pre-referral treatment : rectal artesunate,
quinine IM, artesunate IM, artemether IM.
 ACT
Artesunat/Altemeter dilanjutkan Arterakin tab 1x4 tab selama 3 hr

Artesunat iv 2.4 mgr/KgBB jam 0 12 - 24 dilanjutkan

1.2 mgr/KgBB hr sampai 6 hari, Biasanya pemberian ke 3 sdh sadar
dan dilanjutkan dgn Arterakin 1x4 tab sel 3 hr

Althemether im 3.2 mgr/KgBB hr I, dilanjutkan 1.6

mgr/KgBB sampai OS dapt minum/makan dan dilanjutkan Arterakin
selama 3 hari

Primaquin untuk gamet dan eradikasi utk vivax dan

ovale dosis 0.25-0.5 mgr/KgBB selama 14 hari
untuk Falsiparum 1x3 tab single dose
Pengobatan Suportif (cairan, Oksigen)
Pengobatan komplikasi
Pengobatan koinfeksi HIV
Pengobatan anti malaria kombinasi
Pengobatan Malaria pada ibu Hamil

Pengobatan suportif sangat penting terutama cairan,

biasanya dipasang 2 jalur

Quinine : Loading dose 20 mgr/KgBB drip dalam Dextrose

10%, dilanjutkan oral 10 mgr/KgBB sampai 21 dosis,
dikombinasikan dgn doksisiklin 2x100 mgr selama 7 hari.

Ibu Hamul Trimister I Kina dan Klindamisin

Ibu hamil pada trimester II ACT dpt diberikan
 Pengobatan komplikasi
Koma (serebral malaria A B C
Infus cairan kristaloid kalau ada dehidrasi mis : muntah muntah atau diare
Hiperpireksia Antipiretik (parasetamol)
Kejang Diazepam iv
Hipoglikemia Periksa serial gula darah,
bolus Glukose 40 %,
terutama bila menggunakan Quinine
Anemia Transfusi fresh whole blood kalau Hb <5 gr%
Gagal ginjal Akut Monitor cairan ketat, Furusemide, HD
Edema Paru Restriksi cairan, Diuretik dan Oksigen
Perdarahan spontan Transfusi fresh whole blood,
FFP dan VIt K
Renjatan (shock) Cairan, pertimbangkan Sepsis,
beri Antibiotik spektrum luas
 Manifestation/complication and Immediate management

Coma (cerebral malaria). Maintain airway, place patient on his or her side, exclude
other treatable causes of coma (e.g. hypoglycaemia, bacterial meningitis); avoid
harmful ancillary treatment, such as corticosteroids, heparin and adrenaline; intubate
if necessary.
Hyperpyrexia. Administer tepid sponging, fanning, a cooling blanket and antipyretic
drugs. Paracetamol is preferred over more nephrotoxic drugs (e.g. NSAIDsb).
Convulsions. Maintain airways; treat promptly with intravenous or rectal diazepam or
intramuscular paraldehyde. Check blood glucose.
Hypoglycaemia Check blood glucose, correct hypoglycaemia and maintain with
glucosecontaining infusion.
Severe anaemia. Transfuse with screened fresh whole blood.
Acute pulmonary oedema. Prop patient up at an angle of 45, give oxygen, give a
diuretic, stop intravenous fluids, intubate and add positive end-expiratory pressure/
continuous positive airway pressure in life-threatening hypoxaemia.
Acute renal failure. Exclude pre-renal causes, check fluid balance and urinary
sodium; if in established renal failure add haemofiltration or haemodialysis, or if
unavailable, peritoneal dialysis.
Spontaneous bleeding and coagulopathy
Transfuse with screened fresh whole blood (cryoprecipitate, fresh frozen 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
 Studi Kasus
Seorang penderita wanita umur 47 thn, datang ke IGD dengan keluhan :
tidak sadarkan diri 2 jam yang lalu. 3 hari hari yang lalu os mengeluh
demam dan mual muntah, minum parasetamol OS merasa baik. OS ada
riwayat DM sudah 3 tahun dan masih minum obat dari dokter (obat tdk tau).
Pada pemeriksaan fisik : T=80/50 mmHg ; N =116x/mnt; RR = 28x/mnt;
Suhu= 38.5 C.
Sambil menunggu hasil darah apa yg anda lakukan?
Pemeriksaan Lab apa yg sangat dianjurkan (sesuai lab sdr)?
kalau ternyata hasil Lab : Hb= 8 gr%;lekosit =11.600=trombosit=86.000
DDR= Pf (++++), gf(++); GDS= 165mg%
Pengobatan apa yang dianjurkan?
Ternyata setelah 2 hr pengobatan OS kompos mentis, menguluh sesak
napas RR =32x/mnt;T=130/70 mgr ; Urin =1200cc/hr.
Pemeriksan fisik paru ronki basah halus(+), gallop(-)
Apa yang anda akan lakukan?
Kalau penderita pulang apa yang dianjurkan ?