TY - JOUR
T1 - Fluid resuscitation of adults with severe falciparum malaria
T2 - effects on acid-base status, renal function, and extravascular lung water
AU - Hanson, Joshua
AU - Lam, Sophia
AU - Mohanty, Sanjib
AU - Alam, Shamsul
AU - Pattnaik, Rajyabardhan
AU - Mahanta, Kishore
AU - Hasan, Mahatab
AU - Charunwatthana, Prakaykaew
AU - Mishra, Saroj
AU - Day, Nicholas
AU - White, Nicholas J
AU - Dondorp, Arjen
PY - 2013
Y1 - 2013
N2 - Objective: To
evaluate the efficacy and safety of liberal fluid resuscitation of adults with
severe malaria.
Design, Setting,
Patients, and Methods: Twenty-eight Bangladeshi and Indian adults with
severe falciparum malaria received crystalloid resuscitation guided by
transpulmonary thermodilution (PiCCO) in an intensive care setting. Systemic
hemodynamics, microvascular indices and measures of acidosis, renal function,
and pulmonary edema were followed prospectively.
Results: All
patients were hypovolemic (global end-diastolic volume index < 680 mL/m2) on
enrollment. Patients received a median (range) 3230 mL (390–7300) of isotonic
saline in the first 6 hours and 5450 mL (710–13,720) in the first 24 hours.
With resuscitation, acid-base status deteriorated in 19 of 28 (68%), and there
was no significant improvement in renal function. Extravascular lung water
increased in 17 of 22 liberally resuscitated patients (77%); eight of these
patients developed pulmonary edema, five of whom died. All other patients
survived. All patients with pulmonary edema during the study were hypovolemic
or euvolemic at the time pulmonary edema developed. Plasma lactate was lower in
hypovolemic patients before (rs = 0.38; p = 0.05) and after (rs =
0.49; p = 0.01) resuscitation but was the strongest predictor of
mortality before (chi-square = 9.9; p = 0.002) and after
resuscitation (chi-square = 11.1; p < 0.001) and correlated with
the degree of visualized microvascular sequestration of parasitized
erythrocytes at both time points (rs = 0.55; p = 0.003 and rs =
0.43; p = 0.03, respectively). Persisting sequestration was evident
in 7 of 15 patients (47%) 48 hours after enrollment.
Conclusions: Lactic
acidosis—the strongest prognostic indicator in adults with severe falciparum
malaria—results from sequestration of parasitized erythrocytes in the
microcirculation, not from hypovolemia. Liberal fluid resuscitation has little
effect on this sequestration and does not improve acid-base status or renal
function. Pulmonary edema—secondary to increased pulmonary vascular
permeability—is common, unpredictable, and exacerbated by fluid loading.
Liberal fluid replacement of adults with severe malaria should be avoided.
AB - Objective: To
evaluate the efficacy and safety of liberal fluid resuscitation of adults with
severe malaria.
Design, Setting,
Patients, and Methods: Twenty-eight Bangladeshi and Indian adults with
severe falciparum malaria received crystalloid resuscitation guided by
transpulmonary thermodilution (PiCCO) in an intensive care setting. Systemic
hemodynamics, microvascular indices and measures of acidosis, renal function,
and pulmonary edema were followed prospectively.
Results: All
patients were hypovolemic (global end-diastolic volume index < 680 mL/m2) on
enrollment. Patients received a median (range) 3230 mL (390–7300) of isotonic
saline in the first 6 hours and 5450 mL (710–13,720) in the first 24 hours.
With resuscitation, acid-base status deteriorated in 19 of 28 (68%), and there
was no significant improvement in renal function. Extravascular lung water
increased in 17 of 22 liberally resuscitated patients (77%); eight of these
patients developed pulmonary edema, five of whom died. All other patients
survived. All patients with pulmonary edema during the study were hypovolemic
or euvolemic at the time pulmonary edema developed. Plasma lactate was lower in
hypovolemic patients before (rs = 0.38; p = 0.05) and after (rs =
0.49; p = 0.01) resuscitation but was the strongest predictor of
mortality before (chi-square = 9.9; p = 0.002) and after
resuscitation (chi-square = 11.1; p < 0.001) and correlated with
the degree of visualized microvascular sequestration of parasitized
erythrocytes at both time points (rs = 0.55; p = 0.003 and rs =
0.43; p = 0.03, respectively). Persisting sequestration was evident
in 7 of 15 patients (47%) 48 hours after enrollment.
Conclusions: Lactic
acidosis—the strongest prognostic indicator in adults with severe falciparum
malaria—results from sequestration of parasitized erythrocytes in the
microcirculation, not from hypovolemia. Liberal fluid resuscitation has little
effect on this sequestration and does not improve acid-base status or renal
function. Pulmonary edema—secondary to increased pulmonary vascular
permeability—is common, unpredictable, and exacerbated by fluid loading.
Liberal fluid replacement of adults with severe malaria should be avoided.
U2 - 10.1097/CCM.0b013e31827466d2
DO - 10.1097/CCM.0b013e31827466d2
M3 - Article
VL - 41
SP - 972
EP - 981
JO - Critical Care Medicine
JF - Critical Care Medicine
SN - 0090-3493
IS - 4
ER -