Point-of-care ultrasound to assess volume status and pulmonary oedema in malaria patients

Christina M Pugliese,Laura C Kalkman,Fridia A Obone-Atome,Sabine Bélard,Charlotte C Heuvelings,Ayola A Adegnika,Martin P Grobusch,Ghyslain Mombo-Ngoma,Mischa A Huson,Bayode R Adegbite,Stije J Leopold,Jean R Edoa,Thomas Hänscheid

doi:10.1007/s15010-021-01637-2

Abstract

PurposeFluid management is challenging in malaria patients given the risks associated with intravascular fluid depletion and iatrogenic fluid overload leading to pulmonary oedema. Given the limitations of the physical examination in guiding fluid therapy, we evaluated point-of-care ultrasound (POCUS) of the inferior vena cava (IVC) and lungs as a novel tool to assess volume status and detect early oedema in malaria patients.MethodsTo assess the correlation between IVC and lung ultrasound (LUS) indices and clinical signs of hypovolaemia and pulmonary oedema, respectively, concurrent clinical and sonographic examinations were performed in an observational study of 48 malaria patients and 62 healthy participants across age groups in Gabon.ResultsIVC collapsibility index (CI) ≥ 50% on enrolment reflecting intravascular fluid depletion was associated with an increased number of clinical signs of hypovolaemia in severe and uncomplicated malaria. With exception of dry mucous membranes, IVC-CI correlated with most clinical signs of hypovolaemia, most notably sunken eyes (r = 0.35, p = 0.0001) and prolonged capillary refill (r = 0.35, p = 0.001). IVC-to-aorta ratio ≤ 0.8 was not associated with any clinical signs of hypovolaemia on enrolment. Among malaria patients, a B-pattern on enrolment reflecting interstitial fluid was associated with dyspnoea (p = 0.0003), crepitations and SpO2 ≤ 94% (both p < 0.0001), but not tachypnoea (p = 0.069). Severe malaria patients had increased IVC-CI (p < 0.0001) and more B-patterns (p = 0.004) on enrolment relative to uncomplicated malaria and controls.ConclusionIn malaria patients, POCUS of the IVC and lungs may improve the assessment of volume status and detect early oedema, which could help to manage fluids in these patients.

Highlights

Malaria remains one of the top infectious disease killers globally
On the baseline lung ultrasound (LUS) assessment, we observed that a B pattern, reflecting the presence of interstitial fluid, correlated well with clinical signs that can be associated with pulmonary oedema or a chest infection, including respiratory distress, crepitations on auscultation and reduced oxygen saturation
In particular, is critically important to the management of malaria patients given the risks associated with intravascular fluid depletion and pulmonary oedema

Summary

Introduction

Malaria remains one of the top infectious disease killers globally. Of the 229 million cases reported in 2020, 409,000 resulted in death. Studies show that both adults and children with severe malaria are intravascularly fluid-depleted [6, 7], liberal fluid resuscitation has not been shown to improve acid–base status or renal function in adult patients [6]. This suggests that the primary driver of acidosis is microvascular obstruction rather than hypovolaemia [2], a recent study showed that hypovolaemia reduced cardiac index reserve in adults with severe malaria, which may impact survival by increasing susceptibility to shock [8]. Markers of impaired perfusion are well established in paediatric malaria and are associated with increased mortality [9, 10]

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