[Severe malaria in intensive care units in 2003]

Malaria requiring intensive care is characterized by failure of one or more organ systems and/or development of several metabolic disorders secondary to the presence of Plasmodium faliciparum in the blood. Severe imported malaria in non-immunized adults causes multiple organ failure with variable degrees of altered mental status. Acute pulmonary edema is frequent, jaundice associated with mild disturbance of liver function is consistent, arterial hypertension due to hypovolemia is usual, and acute renal insufficiency is uncommon. Coagulation disorders are generally low-grade, acidosis is an unfavorable prognostic factor, severe hypoglycemia can occur after the beginning of quinine treatment, and anemia is an consistent but discrete symptom. In endemic areas emphasis should be placed on the complications of severe malaria in pregnant women due to the high incidence of hypoglycemia and pulmonary edema. Severe malaria can develop early in children in endemic zones. Presenting signs include cerebral malaria in older children and severe anemia in young children. Quinine is the reference treatment with a bolus of 17 mg/kg followed by a daily maintenance dose of 24 mg/kg. Use of artemether should be restricted to quinine-resistant forms. Total blood exchange transfusion is not recommended. Supportive symptomatic treatment, e.g. mechanically assisted ventilation and kidney dialysis, is required. In endemic zones over 90% of deaths involve children without access to intensive care facilities. Mortality rates associated with management of severe imported malaria in intensive care range from 10 to 30%.