Q J Med 2003; 96: 778
© 2003 Association of Physicians
Correspondence |
Management of shock in children with severe P. falciparum malaria
Sir,I read with interest the recent article by Maitland et al.1 Based on their careful and detailed observations on children with severe P. falciparum malaria, they recommend volume replacement in patients with evidence of hypovolaemia. However, I would like to express certain concerns.
In this study, among children who died, shock and acidosis were present in 84% and 90%, respectively. Thus, acidosis was more commonly observed than shock. As the authors have suggested, acidosis is multifactorial in origin in these cases. Renal failure, commonly seen in the setting of severe malaria, is one of the important contributing factors towards the development of acidosis. Renal failure in severe malaria may not respond to volume replacement, and often necessitates dialysis. In an Indian study, dialysis was required in 92% cases of severe malaria with renal failure.2 In another study, haemodialysis was required in both oliguric and nonoliguric forms of acute renal failure in cases of severe malaria. In this study, 90.2% of patients underwent haemodialysis (at a mean number of 6.5 times and range 1–27).3
If volume replacement is chosen for all children with shock and acidosis, there is a possibility of fluid overload, especially in patients with oliguric acute renal failure. Moreover, the outcome of these children may not improve without dialysis and intense dialysis has been found to be safe and effective in the treatment of acute renal failure in children.4
In conclusion, I would agree with the authors that shock, acidosis and acute renal failure are associated with increased mortality in children with severe malaria. However, intense dialysis instead of fluid replacement may be required in many of these patients for a better survival.
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Neurology Unit Department of Neurological Sciences Christian Medical College Hospital, Vellore India e-mail: drsudhirkumar{at}yahoo.com
References
1. Maitland K, Levin M, English M, Mithwani S, Peshu N, Marsh K, Newton CRJC. Severe P. falciparum malaria in Kenyan children. Q J Med 2003; 96:427–34.
2. Mehta KS, Halankar AR, Makwana PD, Torane PP, Satija PS, Shah VB. Severe acute renal failure in malaria. J Postgrad Med 2001; 47:24–6.[Medline]
3. Wilairatana P, Westerlund EK, Aursudkij B, Vannaphan S, Krudsood S, Viriyavejakul P, Chokejindachai W, Treeprasertsuk S, Srisuriya P, Gordeuk VR, Brittenham GM, Neild G, Looareesuwan S. Treatment of malarial acute renal failure by haemodialysis. Am J Trop Med Hyg 1999; 60:233–7.[Abstract]
4. Filler G. Acute renal failure in children: aetiology and management. Paediatr Drugs 2001; 3:783–92.[Medline]
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