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5.2 Severe Malaria

Table of Contents

In a patient with P. falciparum asexual parasitaemia and no other obvious cause of symptoms the presence of one or more of features listed below classify the patient as suffering from severe malaria.

Diagnostic Criteria

  • Prostration/extreme weakness
  • Impaired consciousness
  • Change of behaviour
  • Convulsions
  • Respiratory distress (due to lactic acidosis and/or pulmonary oedema)
  • Bleeding tendency/DIC
  • Jaundice
  • Circulatory collapse/shock
  • Vomiting everything
  • Inability to drink or breast feed


In severe malaria, blood slide (BS) is a recommended malaria test as it quantify parasitemia. In severe ill patients receiving injectable antimalarial, serial BS investigations monitors level of parasitemia to verify malaria recovery, or if clinical condition is not improving to rule out another serious condition.

  • Blood film for malaria parasites
  • Blood glucose estimation in patients with altered consciousness
  • Haematocrit and/or haemoglobin estimation
  • Lumbar puncture to exclude meningitis (if facilities for LP assessment are available)
  • Serum creatinine or urea– to assess Kidney function
  • Electrolytes– for early detection of acute renal failure
  • Full blood cell count and differential white cell count for additional diagnosis of other infectious diseases
  • Blood gases, pH and anion gap– to diagnose acidosis Radiological investigation: Chest X–ray; look for pulmonary oedema or lobar consolidation

Non-Pharmacological Treatment

Management of severe malaria comprises four main principles namely; rapid clinical assessment, management of emergency conditions, specific antimalarial treatment and supportive care. Severe malaria is a medical emergency. A rapid assessment must be conducted including airway, breathing, circulation, coma, convulsion, and dehydration status. Differential diagnosis must be made. If effective management of severe malaria and supportive care for complications is not possible, patients should be given prereferral treatment and referred immediately to an appropriate facility for continued treatment.

Pharmacological Treatment

A: Parenteral artesunate
Dosage: 2.4 mg/kg in body weight. IV or IM given on admission (time = 0 hour), then at 12 hours and 24 hours for a minimum of 3 injections in 24 hours regardless of patient’s recovery.
Children weighing less than 20 kg Dosage: 3 mg/kg/dose (or higher). Same schedule as indicated above (0, 12, 24 hours)

  • Complete artesunate injection treatment by giving a complete course (3 days) of artemether-lumefantrine (AL) or other ACT

Administration and dosage (60 mg strength): Injectable artesunate has 2-steps dilutions.

  • Step 1: The powder for injection should be diluted with 1ml of 5% sodium bicarbonate solution (provided in each box) and shaken vigorously 2–3 minutes for better dissolving until the solution becomes clear.
  • Step 2: For slow intravenous infusion (3–4 minutes), add 5 ml of 5% dextrose or normal saline, to obtain artesunate concentration of 10 mg/ml. For deep intra–muscular injection, add 2 ml of 5% dextrose or normal saline to obtain a artesunate concentration of 20 mg/ml.

Table 5.3: Dilution of artesunate for injection

Route IV injection IM injection
Strength 30 mg 60 mg 120 mg 30 mg 60 mg 120 mg
Sodium bicarbonate 5% 0.5 1 2 0.5 1 2
Normal saline or 5% of glucose 2.5 5 10 1 2 4
Total (ml) 3 6 12 1.5 3 6
Artesunate concentration (mg/ml) 10 10 10 20 20 20

Table 5.4: Dosage schedule for artesunate injection

Weight Dose ml per dose strength 60mg Vials of Artesunate 60mg needed**
Kg mg/kg i/v i/m*
10 mg/ml 20 mg/ml
<5 3.0 1.5 1 1
5–8 3.0 2 1 1
9–12 3.0 4 2 1
13–16 3.0 5 3 1
17–20 3.0 6 3 1
21–25 2.4 6 3 1
26–29 2.4 7 4 2
30–33 2.4 8 4 2
34–37 2.4 9 5 2
38–41 2.4 10 5 2
42–45 2.4 11 6 2
46–50 2.4 12 6 2
51–54 2.4 13 7 3
55–58 2.4 14 7 3
59–62 2.4 15 8 3
63–66 2.4 16 8 3
67–70 2.4 17 9 3
71–75 2.4 18 9 3
76–79 2.4 19 10 4
80–83 2.4 20 10 4
84–87 2.4 21 11 4
88–91 2.4 22 11 4
92–95 2.4 23 12 4
96–100 2.4 24 12 4

*Half the dose is rounded up to 1ml; **Full vial (s) might not be required for a given weight band. The left–over solution must be discarded within 1hr of preparation and must not be reused


B: Injectable artemether

Artemether should be administered in a dose of 3.2mg/kg body weight loading dose IM stat then 1.6mg/kg body weight (time= 0h then at 24 hrs and 48hrs).

Management of complications

In an attempt to reduce the unacceptably high mortality of severe malaria, patients require intensive care. Clinical observations should be made as frequently as possible. Airway maintenance, nurse on side, fanning if hyperpyrexia is present, fluid balance review:

  • Coma (cerebral malaria): maintain airway, nurse on side, and exclude other causes of coma (e.g. hypoglycemia, bacterial meningitis); avoid giving corticosteroids
  • Hyperpyrexia: fanning, paracetamol if patient can swallow
  • Convulsions: maintain airways; treat with rectal or IV diazepam 0.15 mg/ kg (maximum 10 mg for adults.) slow bolus IV injection. In children, diazepam rectal route should be used. Give a dose of 0.5–1.0 mg/ kg1. If convulsions persist after 10 minutes repeat rectal diazepam treatment as above. Should convulsions continue despite a second dose, give a further dose of rectal diazepam or phenobarbitone 20 mg/ kg IM or IV after another 10 minutes
  • Hypoglycemia: remains a major problem in the management of severe malaria especially in young children and pregnant women. It should be deliberately looked for and treated accordingly. Urgent and repeated blood glucose screening; In children: give 5 mls/kg of 10% dextrose OR 2.5 mls/kg of 25% dextrose as bolus; if 50%dextrose solution is available, it should be diluted to make 25% by adding an equal volume ofwater for injection or normal saline. In adults: give 125 mls of 10% dextrose OR 50 mls of 25% dextrose as bolus. Where dextrose is not available, sugar water should be prepared by mixing 20 gm of sugar (4–level tea spoons) with 200 ml of clean water. 50 ml of this solution is given ORALLY or by nasogastric tube if unconscious.
  • Severe anaemia: transfusion of packed cells if haemoglobin (HB) equal or less than 4 g/dl and/or signs of heart failure and/or signs of respiratory distress
  • Acute pulmonary oedema: Check for restlessness, frothy sputum, basal crepitation, low oxygen saturation (< 95%). Prop patient up to 45 degree angle; review fluid balance andrun patient on “dry side”; give diuretic (IV Furosemide) but avoiding inadequate perfusion of kidneys; set upCentral Venous pressure (CVP) line, give oxygen. Intubation /ventilation may be necessary
  • Acute renal failure: exclude pre–renal causes, check fluid balance and urinary sodium. Ifadequately hydrated (CVP>5cm) try diuretics. Haemodialysis /hemofiltration (or if availableperitoneal dialysis) should be started early in established renal failure.


1Draw the IV preparation into a small syringe and remove the needle. Insert 5 cm of a nasogastric tube into the rectum. Inject the diazepam into the nasogastric tube and flush it with 5 ml of water. If a nasogastric tube is not available, use a syringe without a needle. Hold buttocks together for few minutes to ensure retention and absorption of the medicine

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