General management

Patients should be monitored for clinical and parasitological response to treatment. Rises of parasite count up to 12 h after instituting treatment may be due to the natural parasite cycle and should not be taken as evidence of treatment failure. There should be a fall of more than 75 per cent by 48 h; if there is not, resistant malaria is likely and treatment should be altered. Conventional clinical measures of response are time to recovery of consciousness, time to fever falling below 37.5 °C, and time to parasite count falling by 50, 90, and 100 per cent.

Fluid balance, renal function, and respiratory function should be monitored closely. Both renal and pulmonary function can deteriorate despite a parasitological and clinical response to treatment.

Optimizing fluid balance is the most difficult part of supportive care. Patients with severe malaria are often dehydrated and require initial rehydration. They may also require blood transfusion. Overhydration is easy, with potentially fatal results. The pulmonary complications of malaria have a mortality of around 50 per cent in intensive care units, and these may be compounded by overvigorous hydration. Restoration of plasma volume with careful monitoring should avoid the problems of both hypovolemia and fluid excess. The renal failure seen in malaria is most often due to sequestration of parasites in the kidney, and will not respond to repeated fluid challenges.

Apart from antimalarial drugs and caution with fluids, identifying and treating the complications of severe malaria early is the key to good management. No trials of potentially disease-modifying drugs (such as anti-tumor necrosis factor) have demonstrated any reduction in mortality to date.

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