Malaria: fluid therapy in severe disease

Overview

General background | Focus of the review | Comments on evidence | Search and appraisal summary | Substantive changes at this update | Abstract | Cite as

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General background

Severe malaria mainly affects children aged under 5 years, non-immune travellers, migrants to malarial areas, and people living in areas with unstable or seasonal malaria. Cerebral malaria, causing encephalopathy and coma, is fatal in around 20% of children and adults, and may lead to neurological sequelae in survivors. Severe malarial anaemia may have a mortality rate of over 13%.

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Focus of the review

The main aspect of malaria treatment is the use of appropriate antimalarial medications. Please see previous versions of this overview. For this update, we have focused on fluid resuscitation in people with severe malaria.

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Comments on evidence

All the RCTs we found were in children rather than adults, so may not be directly relevant to all patients. Some of the trials assessed 'bolus' administration of fluid. While all these trials administered boluses of fluid determined by patient weight, the relative size of bolus varied between trials, meaning that 'bolus' is a heterogeneous intervention and care should be taken when interpreting collective findings. Quality of evidence may be reduced due to lack of blinding to the interventions administered, although blinding may be very difficult to achieve when comparing different fluid resuscitation regimens. In some trials, the population included was broader than people with severe malaria and included people with severe febrile illness and impaired perfusion due to causes other than severe malaria.

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Search and appraisal summary

The literature search was carried out in December 2014. For more information on the electronic databases searched and criteria applied during assessment of studies for potential relevance to the overview, please see the Methods section. Searching of electronic databases retrieved 187 studies. After deduplication and removal of conference abstracts, 93 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 82 studies and the further review of 11 full publications. Of the 11 full articles evaluated, two systematic reviews and three RCTs were included.

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Substantive changes at this update

Human albumin New option. One systematic review[21] and three RCTs[8][9][22] added. Categorised as 'unlikely to be beneficial'.

Intravenous fluids New option. One systematic review[21] and three RCTs[8][9][22] added. Categorised as 'unlikely to be beneficial'.

Whole blood or plasma New option. One systematic review added.[23] Categorised as 'unknown effectiveness'.

Abstract

INTRODUCTION: Severe malaria mainly affects children aged under 5 years, non-immune travellers, migrants to malarial areas, and people living in areas with unstable or seasonal malaria. Cerebral malaria, causing encephalopathy and coma, is fatal in around 20% of children and adults, and may lead to neurological sequelae in survivors. Severe malarial anaemia may have a mortality rate of over 13%. The role of fluid resuscitation in severe malaria is complex and controversial. Volume expansion could help to improve impaired organ perfusion and correct metabolic acidosis. However, rapid volume expansion could aggravate intracranial hypertension associated with cerebral malaria, leading to an increased risk of cerebral herniation. METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical question: What is the optimal method of fluid resuscitation in patients with severe malaria? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2014 (BMJ Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 187 studies. After deduplication and removal of conference abstracts, 93 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 82 studies and the further review of 11 full publications. Of the 11 full articles evaluated, two systematic reviews and three RCTs were added at this update. We performed a GRADE evaluation for seven PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for three interventions based on information about the effectiveness and safety of human albumin, intravenous fluids, and whole blood or plasma.

Cite as

Hodgson SH, Angus BJ. Malaria: fluid therapy in severe disease. Systematic review 913. BMJ Clinical Evidence. . 2016 January. Accessed [date].

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