PENATALAKSANAAN

MALARIA BERAT 2011

Dr. Paul Harijanto, SpPD-KPTI

RSU Bethesda GMIM Tomohon

MORTALITY
0.1%

case fatality rate provided

prompt and effective treatment
Ineffective, delayed severe
malaria
Severe malaria, mortality 15 20
%
Untreated severe malaria,
almost always fatal

PROGNOSIS

malaria prognosis score (MPS) : 2.13 + 0.02

(Age) + 0.25 (Creat) - 0.24 (Hb) + 3.05
(Cerebral) + 0.8 (Pregnancy)+ 0.8(Ventilator)
malaria score for adults was (MSA) = 1(severe
anaemia) + 2 (acute renal failure) +
3(Respiratory distress) +4 (cerebral malaria).
The MSA ranges from 0 to 10. The mortality
was 2% for MSA 0 2; 10% for MSA 34, 40%
for MSA 56 and 90% for MSA 7 or more. The
sensitivity is 89.9% and positive predictive
value is 94.1% when 5 is taken as the cut off
value.

Kasus-1a

Female, 30years, admitted 18-10-2000, fever and

unconcious. Fever 7 days, chills and rigor. One day before
admission become unconcious and jaundice. She is
pregnant in 32-34 weeks. She had no history of cough,
abdominal pain , neither diarrhea. She passed small
amount of urin.
Examination :
Severe ill, delirium (GCS:E2/ M4/ V2), pale, jaundice
Fever 38 C, B.P. 110/80 mmHg; pulse 129/minute; resp
22/min. Hear & Lung : normal, Liver & spleen : not palpable
Uterus 2 finger above umbilicus.

What s the appropriate history needed for diagnosis ?

6

Case rsup;YS/18-10-2000

Kasus-1b

Question :

What

are the investigation to make diagnosis ?

Hb. 6.6 gr%; leucocyte 3700/ mm3; platelets 50.000/ mm3

Malaria smear falcip ring ++.

Bl.sugar 55 mg%;
Ureum 146 gr%; creatinine 2,76 mg%,
Bilirubin 16.7 mg%(direct 11.8 mg%),Albumin 2.1 gr%.
Parasite count 3978 par/ 200 leuco

DIAGNOSA ?
7

What is the treatment

Anti

Malaria drug :

A..
Q..

Other

management :

SEVERE MALARIA -2010

DEFINITION : Patient, Plasmosium Asexual parasitemia,with one
or more CLINICAL or LABORATORY FEATURES :
PROSTRATION
Failured to Feed
IMPAIRED CONSCIOUSNESS
RESPIRATORY DISTRESS
MULTIPLE CONVULSIONS, >2x/ 24 hrs
CIRCULATORY COLLAPSE
(Systolic < 70, chlidren < 50 )
PULMONARY EDEMA ( radiology )
ABNORMAL BLEEDING ( spontaneus )
JAUNDICE + other vital organ
dysfunction
HAEMOGLOBINURIA

SEVERE ANAEMIA (< 5 gr%/15 %)

HYPOGLYCAEMIA (<40 mg%)
ACIDOSIS (< 15 mmol/L)
RENAL IMPAIRMENT (> 3 mg%)
HYPERLACTATAEMIA (> 5mmol/L)
HYPERPARASITEMIA (>2%/ 5%)

WHO: Guidelines for the Treatment of Malaria 2010- second edition

MALARIA BERAT
MALARIA SEREBRAL
MALARIA DGN

BILIRUBIN > 3 MG%

GAGAL GINJAL AKUT < 400 ml/24 jam & Kreat > 3 mg%
HIPOGLIKEMI < 40 mg%
SYOK SISTOLIK < 70 mmHg / Anak < 50 mmHg
ANEMIA BERAT HB < 5 gr% / Ht < 15%
EDEMA PARU / ARDS
PERDARAHAN SPONTAN / DIC
KEJANG BERULANG
ASIDOSIS Ph <7.15 , Plasma Bicarb < 15 mmol/L
HAEMOGLOBINURIA
HIPERPARASITEMIA > 5 %
HIPERTERMIA > 40 C

PENYEBAB / ETIOLOGI
Plasmodium

falciparum
Mixed plasmodium ( Falciparum+
vivax)
Plasmodium vivax
Plasmodium knowlesi

PLASMODIUM KNOWLESI
Simian malaria ( Maccaca mullata)
Unusual presentation P. Malariae
Diagnosis by PCR
Acute diare, abdominal pain, jaundice
Algid malaria, hypotension
Renal failure, respiratory failure

BEDA MALARIA BERAT PADA DEWASA &

ANAK
ANAK

Batuk
Kejang
Ikterik
Lama sakit
Lama koma
Hiperparasitemia
Hipoglikemia
Gagal ginjal
Tek.I.K naik
Edema paru
Perdarahan
Ggn brain stem
Sequelae Neuro.

Sering
Sangat sering
Jarang
Pendek (1-2 hr)
Pendek (1-2 hr)
Sering
Sering sebelum Rx
Jarang
Sering/naik
Jarang
Jarang
Lebih sering
> 10 %

DEWASA

Jarang
Sering
Sering
Panjang (5-7 hr)
Panjang (2-4 hr)
Jarang
Sering sesudah Rx/Hml
Sering
Jarang/ normal
Sering
---10 %
Jarang
<5%

Syndromes of severe malaria:

1. Children
1. Severe anemia
2. Metabolic acidosis
3. Cerebral malaria
Exacerbated by:
hypovolemia
hypoglycemia
salicylate toxicity

Renal failure rare

Lung injury/ARDS rare

Syndromes of severe malaria:

2. non-immune adults
Multiorgan failure:
Hyperparasitemia
Acute

renal failure
Jaundice
Metabolic acidosis
Hypoglycemia
Acute respiratory
distress syndrome
Anemia/thrombocytopen
ia
Cerebral malaria

Prognostic value & frequency of SM in adults / children

Children

Adults

+
++
+
++
++
++
++
++
+
+
+
+
+

?
+
++
+
++
+
++
++
+
+
+
+
+
+

Clinical manifestations or
Laboratory finding
Prostration
Impaired counciousness
Respiratory distress ( acidotic breathing )
Multiple convulsions
Circulatory collapse
Pulmonary Edema (radiological)
Abnormal bleeding
Jaundice
Haemoglobinuria
Severe Anemia

Children

Adults

++
+
++

++
+++

++
++
++
+/
-+ /
-+
+/
-++
+

+
+
+
+
+
++
++
+

Classifications SM in Children

Group 1: (require parenteral Rx & Support.Tx )

1. Prostration ( inability to sit upright), 3 subsgroup :

2.

Respiratory distress ( acidotic breathing

Mild nasal flaring &/ or mild intercostal indrawing

Severe mark intercoctal indrawing or deep acidotic

Group 2 (able to take oral Rx, require supervised) :

1.
2.

Prostrate but fully concious

Prostrate with impaired conciousness not coma
Coma

Haemoglobin < 5 gr% or haematocrit < 15%

> = 2 convulsions in 24 hours

Group 3 : require parenteral Tx because of

persistent vomiting, not in group 1 or 2.

Penilaian awal
Amankan

Airway, Breathing, Circulation

Timbang berat badan untuk dosis obat
Pasang i.v. line
Periksa : gula darah, Hb, hitung parasit,
ureum, kreatinin, analisa gas darah,
kadar asam laktat
Pemeriksaan fisik yang teliti terutama
tingkat kesadaran ( GCS )
Ukur balans cairan yang tepat

MANAGEMENT SEVERE
MALARIA
SPECIFIC
ANTI

TREATMENT

MALARIAL DRUGS

ORGAN

FAILURE TREATMENT
SUPPORTIVE TREATMENT
ANCILLARY TREATMENT

ANTI MALARIAL THERAPY FOR S.M

Artesunate/

ARTS ( i.v./ i.m / supp )

Artemether / ARTM (i.m.)
Arte-ether (i.m )
Artemisinin ( supp )
Dihydro-artemisinin ( supp )
Artelinate ( i.v)

QUININE
QUINIDINE

SEVERE MALARIA

Required parenteral or suppossitoria treatment

Decreased parasitemia rapidly
Less side effect
Quinine vs Artemisinin ( ARTM , ARTS )
ARTM trend to have low mortality but coma
recovery prolong, more convulsion
ARTS Better than Quinine ( SEQUAMAT )

RECOMMENDED DOSES OF ANTI MALARIAL DRUGS FOR

TREATMENT OF SEVERE MALARIA

DRUGS
ARTESUNATE

Artemeter

Artemisinin

Dosis

SIDE EFFECTS

i.v. 2,4 mg/kg BB pada jam 0, dan

jam 12, kemudian dilanjutkan
jam 24, 48 dst sampai 7 hari.
Dosis total 17 18 mg/ 7 hari
( 1 Amp= 60 mg)
3.2 mg/kg im pada hari I dibagi 2
dosis, dilanjutkan 1.6 mg/kg/
Neurotoxicity in
hari. TIDAK iv (1 amp = 80
animal not human
mg)
Suppositories, 10 mg/kg at 0 & 4
hr followed by 7 mg/kg at
24,36,48 & 60 hrs.

WHO 2006 : AS is the recommended FIRST CHOICE in area

low transmission

Dosis ARTEMISININ PADA MALARIA

BERAT
0 JAM

12.J

24.J

48.J

72.J

2.4
2.4
Mg/
Mg/
KgBB KgBB

2.4
Mg/
KgBB

2.4
Mg/
KgBB

2.4
Mg/
KgBB

ARTESUNATE I.V/ I.M

* ARTEMETER , hanya I.M , dosis 1,6 mg/kg BB

Max 7 hari

SEQUAMAT
( 2005, Lancet, Agst )
VS

AQUAMAT
2010, Lancet, Nov )

AQUAMAT

( African QUinine Artesunate MAlaria Trial )

Findings 5425 children were enrolled; 2712 were assigned to artesunate and
2713 to quinine. 230 (85%) patients assigned to artesunate treatment died
compared with 297 (109%) assigned to quinine treatment (odds ratio [OR]
stratified for study site 075, 95% CI 063090; relative reduction 225%,
95% CI 81369; p=00022).
Incidence of neurological sequelae did not differ significantly between
groups, but the development of coma (65/1832 [35%] with artesunate vs
91/1768 [51%] with quinine; OR 069 , 95% CI 049095; p=00231),
convulsions (224/2712 [83%] vs 273/2713 [101%]; OR 080,066097;
p=00199), and deterioration of the coma score (166/2712 [61%] vs
208/2713 [77%]; OR 078, 064097; p=00245) were all significantly less
frequent in artesunate recipients than in quinine recipients.
Post-treatment hypoglycaemia was also less frequent in patients assigned
to artesunate than in those assigned to quinine ( 48/2712 [18%] vs 75/2713
[28%]; OR 063, 043091; p=00134).

ARTESUNATE
I.V / I.M

ARTEMETHER I.M
1 Amp = 80mg

1 Fl = 60 mg

RECOMMENDED DOSES OF ANTI

MALARIAL DRUGS FOR TREATMENT OF
SEVERE/CEREBRAL MALARIA
DRUGS
Quinine

20 mg of dihydrochloride salt/kg
by iv infusion over 4 hr, then
after loading, followed by 10
mg/kg over 4 hr every 8 hr.
Patients should not received
quinine or mefloquine within
last 24 hr
Alternatively, 7 mg of salt/kg
can be infused over a period
of 30 min, followed by 10 mg
salt/kg over a period of 4 hr,
or
10 mg of salt/kg (500 mg for
adult) by i.v infusion over 8 hr
continously 3 x a day

SIDE EFFECTS
Hypoglycemia,
chinchonism,
tinnitus, hearing
impairment,
nausea, dysphoria,
vomiting, prolonged
QT interval,
dysrhythmias,
hypotension

Pengobatan Kina HCl/di-hidroklorid parenteral

Loading

SETELAH KESADARAN MEMBAIK/DAPAT MINUM :

GANTI PER-ORAL 10 MG/KGBB/8 JAM
SAMPAI HARI KE-7

20 mg/kgBB IV infus/100-200 ml/4 jam

Berat badan . Kg
Tak pakai Kina/Mefloquin 24 jam sebelumnya

APABILA SETELAH 48 JAM

KEADAAN TIDAK MEMBAIK :
GCS TETAP/MEMBURUK
BILIRUBIN / KREATININ NAIK
URIN KURANG / TAK ADA

Tidak lanjut usia atau QT/QTc int. panjang

Standard

10 mg/kgBB IV

DOSIS DITURUNKAN 30-50%

infus/200 ml/4 jam

Infus kosong 8 jam

(tanpa kina)

10 mg/kgBB
IV infus 200 ml/4 jam
diulang tiap 8 jam

10 mg/kgBB
IV infus 200 ml/4 jam
Infus kosong 8 jam
(tanpa kina)

12
WAKTU (JAM)

16

20

24

Dextrose 5%

Kina

Microdrips
100-200 cc

CARA PEMBERIAN

KINA PADA

MALARIA BERAT

Cairan
Maintenance

Piggy
Back

Pengobatan Kina HCl/di-hidroklorid parenteral

SETELAH KESADARAN MEMBAIK/DAPAT MINUM :

GANTI PER-ORAL 10 MG/KGBB/8 JAM
SAMPAI HARI KE-7
APABILA SETELAH 48 JAM
KEADAAN TIDAK MEMBAIK :
GCS TETAP/MEMBURUK
BILIRUBIN / KREATININ NAIK
URIN KURANG / TAK ADA

DOSIS DITURUNKAN 30-50%

500 mg Kina HCl (1 amp)

dalam 500 cc Dextrose 5%

500 mg Kina HCl (1 amp)

dalam 500 cc Dextrose 5%

12
WAKTU (JAM)

500 mg Kina HCl (1 amp)

dalam 500 cc Dextrose 5%

16

20

24

Penyesuaian dosis pada gangguan Fungsi Organ

Tidak perlu penyesuaian dosis obat derivat artemisinin

pada gangguan fungsi hati dan atau ginjal
Dosis kina parenteral diturunkan 1/3 setelah 48 jam
pemberian pada :
Gagal ginjal akut
Gangguan fungsi hati
Tidak ada perbaikan klinis setelah 48 jam
Bila pasien sudah hemodialisis tidak perlu
pengurangan dosis kina

Pengobatan Bumil Malaria

Berat
Trimester 2 -3 , durante/ post partum :

Artesunate i.v 2,4 mg/kg BB jam 0, 12,

24, 48 dst, bila sadar/ bisa minum
obat ganti oral sampai 5 7 hari. Bila
oral artesunate 2 mg/kg BB diberikan
sampai hari ke-7 (ars + clindamycin)
Trimester 1 : Kina HCl perinfus, 20
mg/kg BB dosis awal dan 10 mg/kg BB
selanjutnya

Pengobatan lanjutan

Setelah pasien sadar/KU membaik, tx. Awal parenteral

dapat diubah dgn. Tx. Oral. Pengobatan parenteral minimal
3 x pemberian ( 0, 12 dan 24 jam )
Diteruskan dengan :
ACT dosis lengkap (selama 3 hari): AL , AS + AQ
Artesunate/artemether tab. (total 7 hari ) + doksisiklin 35 Kg BB 1 kali sehari selama 7 hari
Kina tab.(total 7 hari) + doksisiklin 7 hari
Bagi bumil, anak-anak : doksisiklin diganti dengan
klindamisin 10 mg/Kg BB 2 kali sehari

Pengobatan pre-referal
Dianjurkan

sebelum merujuk setidaknya

dosis pertama obat antimalaria parenteral
sudah diberikan.
Obat yang dipilih :
Artemether i.m. atau Artesunate i.m.
Artesunate atau artemisinin supositoria
Kina i.m.
Kina i.v. (didampingi petugas medis ) ??

A 28years old lady unconcious & fever since < 24 hours before admission in R
On 9 September 2002 at 10.00 a.m.

Falcip : +
gamet
Hb. 12.3
Bl. Sugar :
105 mg%
Bill. Dir: 6.7
Bill.indir: 1.5
SGOT :172 u
SGPT : 109u/
GGT : 48 u/L
Al.PO4: 369
Creat : 1.5 0
pH : 7.4
HCO3 : 23.8
pO2 : 80
pCO2: 37
B.Ex.:- 0.9
K : 3.2
CSF :
Cell ; 200
Lymph. :94%

Chest
X-ray
18 hours
After
admission

Cerebral Malaria with infiltrate both lung

MM1-3

48 hours after quinine treatment

MM1-4

TREATMENT OF ORGAN FAILURE

ENCEPHALOPATHY/
RENAL

CONVULSION

FAILURE
ACIDOSIS
HYPOGLYCAEMIA
HYPERBILIRUBINAEMIA
RESPIRATORY FAILURE
HYPOTENSION
SEPSIS
SEVERE ANAEMIA

ACUTE KIDNEY INJURY (AKI)

Malaria

related Acute Kidney Injury (MAKI)

Penurunan fungsi ginjal dalam 48 jam :
Peningkatan

serum kreatinin 0.3 mg/dL, atau

Peningkatan serum kreatinin 50% dan nilai
dasar, atau
Penurunan urin output 0.5 ml/kg/jam untuk 6
jam
WHO

: serum kreatinin > 3 mg/dL

Sering pada malaria dewasa dan jarang
pada anak

PULMONARY MANIFESTATION IN MALARIA

Historically

Bronchitic
Pneumonic
Bronchopneumonic

Acute

Lung Injury (ALI)

Acute Respiratory Distress
Syndrome (ARDS)

A.R.D.S
Occurs

in P. Falciparum, P. Vivax, P. Ovale & ? P.

Knowlesi
Common in adult than children, pregnancy and
non-immune
Mechanism : Increased alveolar cappilary
permeability intravascular fluid loss into the
lungs
Presentation : initial presentation or after initiation
treatment
Clinical : acute onset dyspnea respiratory failure

CLINICAL FINDING

Manifest abrupt onset dyspnoea, cough, tightness in

the chest that progresses rapidly over a few hours
Disorientation and agitation is frequently present.
Physical examination : signs of respiratory distress ( air
hunger, use of accessory muscles of respiration,
suprasternal and intercostal indrawing ), central and
peripheral cyanosis (arterial hypoxaemia), basal
crepitations and expiratory wheezing.
In these patients, high parasitaemia,acute renal failure,
hypoglycemia, metabolic acidosis, disseminated
intravascular coagulation (DIC), and bacterial sepsis
usually co-exist.

Chest radiography :
Bilateral

frontal opacities (alveolar

pattern), increased interstitial markings
The cardiac size is usually normal
Rarely, thickening of lung fissures,
interlobular septal lines
Pleural effusion
In assisted ventilator :
complications

pneumothorax,
pneumomediastinum , pneumonia may occur

GENERAL SUPPORTIVE
MEASURES
Patients should be treated in an ICU

In endemic areas treatment should be

commenced as early as possible, sometimes
before positive parasitology
Patients should be weighed so that dose of
anti malarial can be calculated
IV fluids should be given to maintain fluid
balance and caloric requirements. A central
line and monitoring of central venous
pressure may be necessary, especially in
elderly. All intake should be recorded carefully
Airway, Oxygen requirement
Treat hyperpyrexia

GENERAL SUPPORTIVE
MEASURES

Urinary catheterization should be used to monitor

output
Patients should be observed for vomiting. To
ensure patients safety, cot-sides may be required
Regular re-positioning of patient is necessary to
prevent development of pressure sores
Nasogastric tube should be avoided because of the
risk of aspiration
MONITORING GCS & VITAL SIGN
LAB : FBC, GLUCOSE, PAR.COUNT, CREATININE, UREUM,
BLOOD GAS, URINE S.G, SODIUM, POTASSIUM.
PREVENT : SHOCK, SEPTICAEMIA, ACIDOSIS, ARDS,
HYPOGLYCAEMIA, ASPIRATION, BEDSORES.

KEY SUCCEED FOR MANAGING

SEVERE MALARIA
Accuracy

diagnosis ( microscopic
biochemical )
Malaria drug ( to combat resistency )
Ability to treat organ failure ( ICU &
Medical equipment )
Good man power( nurses --- doctor )
Good referral system

Treatment Severe Malaria

-2010

Severe

Malaria is a medical emergency

Adult : Artesunate iv / im
Children : Artesunate iv/im, Quinine
iv/im, Artemeter im
Give Parenteral at least 24 hours
Swicth to oral : ACT, artesunate +
clindamycin/doxycyclin, quinine + Cl/dx
If not posibble, give pre-referal Rx, then
referred immediately

UNTUK DOKTER SPESIALIS

Penanganan insufisiensi serebral

Oksigenasi
Pencegahan

kejang : diazepam,

luminal, largactil
Mencegah

trauma/ jatuh

Mengatasi

anxiety, delirium state

Convulsions
I.v.

diazepam 10 mg adult or rectal

0.5-1.0 mg/kg
i.m paraldehyde o.1 mg/kg adult
Repeated conv- chlormethiazol
infussion 0.8 %,
Phenytoin 5 mg/kg i.v. 20 minutes
Fosphenytoin 7.5 mg/kg i.v 20
mnutes

PENANGANAN IKTERIK
Tidak

ada yang khusus

Hati-hati hipoglikemia
Hati-hati terhadap perdarahan
Pemberian vit. K pada ikterus yang
dalam/ tanda perdarahan : 10 mg/
hari selama 3 hari.
Ulangi bilirubin, SGOT/ SGPT hari ke
-3

35 th, pria,
Demam 3 har
Sdh mnum CQ
MRS 6-10-02
Falcip ++ 0.4
H1: Par 0.8 %
H2: Par 0.4%
H3: Par 0.1%
Bil TT 19 mg%
Hari III :
Bill 8.7 mg%

HYPOGLYCAEMIA ( Bl. Sugar < 40 mg% )

Coma,

20 -50 ml 50% dextrose i.v. 5 10

minutes ( routine is not recommended )
Infussion 10 % dextrose ( children 5%
dextrose) beware hyponatremia
Hypoglycaemia may developed Day 1 --- 7
Pushed 50% dextrose if necessary
Glucagon injection
Via nasogastric , beware gastric distension
In peritoneal dialysis, add glucose in dialysis
fluid
Somatostatin analoque octreotide (Sandostatin)

Malaria Retinopathy
A. Gambaran retina pada
penderita malaria serebral
GCS 14, dengan anemia Hb
8.2 gr%. Tampak gambaran
perdarahan dan papiledema.
B. Gambaran retina pada
penderita malaria serebral
GCS 8, edemaparu dan
demam kencing hitam.
Tampak gambaran pemutihan
retina.
( Maude RJ, Beare NAR, et
all, Trans. R. Soc. Trop.Med &
Hyg, 2009, 103:665-671)

MANAGEMENT ACUTE KIDNEY INJURY

Appropriate

Anti-Malaria
Maintenance Fluid & Electrolytes
Renal Replacement therapy
Treatment Complications
Managemeni Infections
Avoids nephrotoxics drugs

Fluid & Diuretics

Oliguria/

dehydrated : infussion of N.
saline 20 ml/ kg BW/ 60 minutes
auscultation,

JVP observation/ 200 ml

CVP monitoring ( 0 -- + 5 )
No urine - diuretic challenge
Furosemide

40 mg initially, no urine
100 mg, 200 mg, 400 mg every 30
minutes, no urine , dopamine 2.5 5
ug/ kg/ min ( no improved outcome )

DOPAMINE
2.5

ug/kg/ min improved RBF index

37 % and cardiac output 35 %
10 ug/kg/ min NOT
Epinephrine, dopamine , no role in
renal oxygen supply
Vasopressine ?
Albumin ??

DIALYSIS
Early

dialysis improved survival

Intermittent HD (daily/ alternating)
Continuous venovenous hemofiltration
Continuous artriovenous hemofiltration
Peritoneal dialysis LESS effective
Indications :
Clinical

: uremic symptoms, volume overload

( pulm. Edema, congest heart failure ), pericardial
rub.
Lab : HCO3 < 15 meq/ L, K > 6.5 meq/L

Peritoneal dialysis
in malaria
with renal failure

45 yrs female, Irianish,

No, fever, tired.
Falcip ++, Hb. 13.7, L. 730
Ureum 211, Creat. 7.0mg%
Bill.Ttl. 1.74 mg%
Glucose 128 mg%
GCS 15
Day 3 : ureum 133, creat 5
Day 6 : ureum 104, Creat 4
Day 2. P.count 390
Day 3. P.count 3
Day 4. P.count 5
Day 5 6 : smear : negativ
Dialysis D1 6 .
Death on day 7.

Adequacy of Dialysis
Dialysis

is considered adequate
when the post-dialysis creatinine
and urea levels decrease to 50% or
less of the predialysis values.

MANAGEMENT OF ACUTE RESPIRATORY

DISTRESS SYNDROME

PRINCIPLES :
* Early Diagnosis
* Rapid Rx anti-malarial
* Assisted ventilation
* Consider aggravating factors :
- bacterial sepsis
- secreting obstructing airways
- pneumothorax

Management ALI/ ARDS

ICU
Supported : prevent nosocomial infection, GI bleed,
thrombo-embolism; adequate nutritional enteral intake
Monitoring oxygen saturation
Fluid : conservative ( 136 + 491 ml) , CVP 8 12
mmHg.
Adrenaline is best avoided and other vasopressors such
as dopamine should be preferred
Spontaneous ventilation: a face mask with a high O2 to
deliver FIO2 of up to 0.5 to 0.6.
FI O2 >0.6, CPAP >10 cm H2O mechanical ventilator

Cerebral Malaria, resisten Quinine , Respiratory Failure

in Manado Hospital

CM-ARDS, RSUP 2000

Indications for prophylactic mechanical ventilation before

severe malaria patients deteriorate to respiratory failure !
Normal Value

Respiratory rate
Respiratory muscle
Tidal volume (ml/kg)
FEV1 (ml/kg)
Inspired O2 (cmH2O)
Pa O2 (torr)
P(A-aDO2) (torr)
Minute vent (l/min)
PaCO2(torr)
VD/VT

12 - 20
respiratory
65 - 75
75 - 100
75 - 100
75 - 100
25 - 65
> 80
35 - 45
0.25-0.40

Indications for M.V

> 35
alternans/paradoxical
abdomen
< 15
< 15
< 15
< 70(oxygen mask)
> 450
> 10 (at rest)
.> 55
> 0.6

METABOLIC ACIDOSIS
Occur

in :
- acute renal failure
- hypovolaemia
- shock
- pulmonary oedema
- hyperparasitemia
Management :
* Dialysis
* Sod.bicarbonate if pH< 7.15, beware
of sodium overload Pulm edema
* Preverable THAM tris (hydroxymethyl)amino
methan, no sodium
* Pyruvate dehydrogenase activator dichloro
acetate

HYPOTENSION (algid malaria)

Causes:

gram - ve bacteriaemia,

MOF
Management :
1. CVP : 0 -- 5 cm H2O with
crystalloid/
colloid infusion
2. I.V. Dopamine +/ dobutamine
3. Blood culture
4.Antibiotic ( Carbapenem/ Ceph. IV)

HIPERPARASITEMIA
Bila parasit > 5 %, pada daerah transmisi rendah/ tak stabil
atau hipo endemik
INDIKASI

Exchange Transfussion :

Parasitemia

> 30%, tanpa komplikasi

Parasitemia > 10%, + Malaria berat
Parasitemia > 10% + gagal obat 12 24 j
Parasitemia > 10% + prognosa jelek : usia
lanjut, adanya sizon drh tepi.
WHO 2006 : no consensus
no recommendation

Penatalaksanaan
hiperparasitemia
Rekomendasi WHO 2006 :
Hiperparasitemia tanpa tanda-tanda malaria
berat lainnya dapat diterapi dengan obat
derivat artemisinin oral, dengan syarat :
Pasien harus dimonitor ketat selama 48 jam
pertama setelah mulai terapi
Jika pasien tidak dapat peroral, segera terapi
parenteral
Pasien non-imun dengan hiperparasitemia > 20
% harus mendapat terapi parenteral

Cornerstone of Management Sepsis

early

goal directed therapy

lung protected ventilation,
broad spectrum antibiotic
activated protein C 13

Indications Anti-biotic in Children

with SM
Children with local bacterial
Infection
Children with severe respiratory
distress
Children with shock
Children with coma /
encephalopathy where lumbal
puncture not done

TINDAKAN TERHADAP KOMPLIKASI

Manifestasi/ Komplikasi
Coma (malaria serebral)

Tindakan awal
Pertahankan oksigenasi, letakkan pada sisi tertentu, sampingkan penyebab
lain dari coma (hipoglikemi, stroke, sepsis, diabetes coma, uremia, gangguan
elektrolit ),hindari obat tak bermanfaat, intubasi bila perlu.

Hiperpireksia

Turunkan suhu badan dengan kompress, fan, air condition, anti-piretika

Convulsi/kejang

Pertahankan oksigenasi, pemberian anti-kejang iv/ per rectal diazepam, i.m.

paraldehyde
Beri 50 ml dextrose 40% dan infus dextrose 10% smapai gula darah stabil, cari
penyebab hipoglikemia
Berikan transfusi darah darah segar, cari penyebab anemianya

Hipoglikemia ( Gl darah < 40 mg%)

Anemia berat ( Hb < 5 gr% atau
PCV < 15% )
Edema Paru Akut , sesak nafas,
resp > 35 x
Gagal Ginjal Akut
Perdarahan spontan/ koagulopati
Asidosis Metabolik
Syok
Hiperparasitemia

Tidurkan 450, oksigenasi, berikan Furosemide 40 mg iv, perlambat cairan infus,

intubasi-ventilation PEEP,
Kesampingkan gagal gijal pre-renal, bila dehidrasi koreksi; bila gagal ginjal
renal segera dialysis
Berikan vitamin K 10 mg/ hari selama 3 hari; transfusi darah segar; pastikan
bukan DIC
Kesampingkan/ koreksi bila hipoglikemia, hipovolemia, septikemia. Bila perlu
dialysis/ hemofiltrasi
Pastikan tidak hipovolemia, cari tanda sepsis, berikan anti-biotika spektum luas
yang adequat
Segera anti malaria (pilihan artesunate), transfusi ganti (exchange transfusion)

A well trained Malaria team in Emergency Unit, Timika Hospital

PAKATUAN WO PAKALAWIREN
Sampai Baku Dapa !
Dr. Paul Harijanto, Sp.PD-KPTI
Div. Penyakit Tropik & Infeksi
SMF/ Bag. Penyakit Dalam
FK UNSRAT/ RSUP Manado
RSU Bethesda -Tomohon
Telp.:
0431-351024/046 ( RSU Bethesda)
0812-430-2869 ( HP)
0431-351187 (Res)
E-mail : paulharijanto@gmail.com

Case Malaria , complicated

51

years women, admitted with history 4

days fever with breathless, temp 37.5,
BP 150/100, pulse 108 : resp. : 36x/menit
No history of DM, Hpt -, previous
admission
12 hrs after hospitalization BP 70/50,
pulse 120x/min, temp 35.6, Kussmaul
breathing
CX-ray:heart enlarged, lungs clear, ECG :
sinus tachycardia, no evidence of infarct

 Hb:

16,3 , WBC: 17900/uL, Diff Leuco :

-/-/82/19/-, Trombo : 109.000. Malaria
falciparum: +++, 1100/ 200 WBC, bl.
Sugar: HI ,1015mg%, 900mg%, Bil.
Total:2.47, bil direct:1.15 mg%,ureum:
86.4 mg%, creatinine :2.87mg%,
sodium: 124 meq/L, potassium: 6.3
meq/L
Question :
Diagnosis

? ( 3 issue )
Priority treatment ?
Anti-malaria

?
Terapi diabetes ?
Hemodynamic ? (Cairan)
Others ? (electrolyte, infection, renal function )