Patients with severe malaria require intensive nursing, in an intensive care unit if possible. Following the initial assessment and the start of antimalarial treatment, clinical observations should be made as frequently as possible. These should include recording of vital signs, with an accurate assessment of respiratory rate and pattern, coma score, and urine output. Blood glucose should be checked, using rapid stick tests every 4 h if possible, particularly in unconscious patients. Convulsions should be treated promptly with intravenous or rectal diazepam or intramuscular paraldehyde.
Fluid requirements should be assessed individually. Adults with severe malaria are very vulnerable to fluid overload and there is a thin dividing line between underhydration, and thus worsening renal impairment, and overhydration, with the risk of precipitating pulmonary oedema. If the patient becomes oliguric (<0.4 ml of urine/kg bw per hour) despite adequate rehydration, and the blood urea or creatinine are rising or already high, then fluids should be restricted to replace insensible losses only. Children, on the other hand, are more likely to be dehydrated and may respond well to a bolus of fluid. The fluid regimen must also be tailored around infusion of the antimalarial drugs. Central venous pressure should be maintained at 0-5 cm. If the venous pressure is elevated (usually because of excessive fluid administration), the patient should be nursed with the head raised at an angle of 45o and, if necessary, intravenous furosemide should be given. If available, heamofiltration should be started early for acute renal failure or severe metabolic acidosis unresponsive to rehydration.
If blood glucose is <2.2 mmol/l then hypoglycaemia should be treated immediately (0.3-0.5 g/kg bw of glucose). Hypoglycaemia should be suspected in any patient who deteriorates suddenly. Stick tests may overestimate the frequency of hypoglycaemia, so laboratory confirmation may be necessary.
Patients with acute pulmonary oedema should be nursed in an upright position and given oxygen, and filling pressures on the right side of the heart should be reduced with whichever treatments are available (loop diuretics, opiates, venodilators, venesection, haemofiltration, dialysis). The right-sided pressure should be reduced to the lowest level compatible with an adequate cardiac output. Positive pressure ventilation should be started (if available) early if the patient becomes hypoxic.
Fewer than 5% of patients with severe malaria develop clinically significant disseminated intravascular coagulation. These patients should be given fresh blood transfusions and vitamin K. Patients with secondary pneumonia should be given empirical treatment with a third-generation cephalosporin, unless admitted with clear evidence of aspiration, in which case penicillin or clindamycin is adequate. Children with persistent fever despite parasite clearance may have a systematic Salmonella infection, although in the majority of cases of persistent fever no other pathogen is identified after parasite clearance. Urinary tract infections are common in catheterized patients. Antibiotic treatments should take account of likely local antibiotic sensitivity patterns.
