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Transfusion for respiratory distress in life-threatening childhood malaria
M English1, C Waruiru, K Marsh
1Clinical Research Centre, Kenya Medical Research Institute Kilifi Unit, Kenya.
Insights
Severe anemia and hypovolemia contribute to metabolic acidosis and respiratory distress in children with life-threatening malaria. Prompt fluid resuscitation, especially blood transfusion for anemia, rapidly improves outcomes.
Area of Science:
- Pediatric critical care medicine
- Infectious diseases
- Malariology
Background:
- Life-threatening childhood malaria frequently presents with respiratory distress and metabolic acidosis.
- Severe anemia and hypovolemia are common co-morbidities in these critically ill children.
Purpose of the Study:
- To investigate the role of severe anemia and hypovolemia in the pathogenesis of metabolic acidosis in children with life-threatening malaria.
- To evaluate the effectiveness of fluid resuscitation and blood transfusion in treating these conditions.
Main Methods:
- Prospective data collection during resuscitation in 24 children with severe malaria.
- Monitoring of clinical parameters, central venous pressure (CVP), lactate, and creatinine.
- Assessment of treatment response to fluid administration and blood transfusion.
Main Results:
- Children with severe anemia had significantly higher lactate levels compared to non-anemic children.
- Hypovolemia was associated with reduced creatinine clearance.
- Fluid resuscitation and blood transfusion led to rapid decreases in blood lactate, particularly in severely anemic children.
- Two of three children with persistent acidosis despite resuscitation died.
Conclusions:
- Metabolic acidosis and respiratory distress in severe childhood malaria are significantly influenced by severe anemia and hypovolemia.
- Aggressive fluid resuscitation and blood transfusion are effective and safe treatment strategies.
- Early recognition and management of anemia and hypovolemia are crucial for improving outcomes in severe malaria.
Abstract:
We have prospectively collected information during resuscitation in 24 children with life-threatening malaria. All had clinical respiratory distress and 16 were severely anemic (hemoglobin < or = 5 g/dL) on admission. Central venous pressure (CVP) measurements were normal (< or = 5 cm of water) prior to treatment but all had a metabolic acidosis. The geometric mean lactate level was significantly higher in children admitted with severe anemia than in those without severe anemia (11.2 mmol/l versus 4.2 mmol/l; P = 0.009). Hypovolemia (a CVP on admission < 0 cm of water) was associated, although not significantly, with a higher admission plasma creatinine concentration (94 mumol/l versus 64 mumol/l; P = 0.06) and probably contributed to the severely reduced creatinine clearances (0-39 ml/min/1.73 ml2) found in 12 of the 13 children in whom this was assessed in the first 24 hr. Treatment resulted in a rapid decrease in blood lactate in 16 of the 13 children in whom this was assessed in the first 24 hr. Treatment resulted in a rapid decrease in blood lactate in 16 of the 20 children transfused, which was most dramatic in severely anemic children, who were rapidly resuscitated. In nonanemic children, early and rapid administration of normal saline usually resulted in both metabolic and clinical improvement. However, in three children, two of whom died, acidosis persisted despite resuscitation. Metabolic acidosis often accounts for respiratory distress in life-threatening childhood malaria. Severe anemia and hypovolemia appear to play major roles in its pathogenesis, are readily treatable, and there appears to be little risk of congestive cardiac failure even with an aggressive approach to fluid replacement.