Abstract
BackgroundAdults with severe malaria frequently require intravenous fluid therapy to restore their circulating volume. However, fluid must be delivered judiciously as both under- and over-hydration increase the risk of complications and, potentially, death. As most patients will be cared for in a resource-poor setting, management guidelines necessarily recommend that physical examination should guide fluid resuscitation. However, the reliability of this strategy is uncertain.MethodsTo determine the ability of physical examination to identify hypovolaemia, volume responsiveness, and pulmonary oedema, clinical signs and invasive measures of volume status were collected independently during an observational study of 28 adults with severe malaria.ResultsThe physical examination defined volume status poorly. Jugular venous pressure (JVP) did not correlate with intravascular volume as determined by global end diastolic volume index (GEDVI; rs = 0.07, p = 0.19), neither did dry mucous membranes (p = 0.85), or dry axillae (p = 0.09). GEDVI was actually higher in patients with decreased tissue turgor (p < 0.001). Poor capillary return correlated with GEDVI, but was present infrequently (7% of observations) and, therefore, insensitive. Mean arterial pressure (MAP) correlated with GEDVI (rs = 0.16, p = 0.002), but even before resuscitation patients with a low GEDVI had a preserved MAP. Anuria on admission was unrelated to GEDVI and although liberal fluid resuscitation led to a median hourly urine output of 100 ml in 19 patients who were not anuric on admission, four (21%) developed clinical pulmonary oedema subsequently. MAP was unrelated to volume responsiveness (p = 0.71), while a low JVP, dry mucous membranes, dry axillae, increased tissue turgor, prolonged capillary refill, and tachycardia all had a positive predictive value for volume responsiveness of ≤50%. Extravascular lung water ≥11 ml/kg indicating pulmonary oedema was present on 99 of the 353 times that it was assessed during the study, but was identified on less than half these occasions by tachypnoea, chest auscultation, or an elevated JVP. A clear chest on auscultation and a respiratory rate <30 breaths/minute could exclude pulmonary oedema on 82% and 72% of occasions respectively.ConclusionsFindings on physical examination correlate poorly with true volume status in adults with severe malaria and must be used with caution to guide fluid therapy.Trial registrationClinicaltrials.gov identifier: NCT00692627
Highlights
Adults with severe malaria frequently require intravenous fluid therapy to restore their circulating volume
Patients were defined as having malaria if asexual forms of Plasmodium falciparum were present on blood film or, if expert microscopy was not immediately available, an immunochromatographic rapid diagnostic test (Paracheck Pf, Orchid Biomedical Systems, India) was positive
Despite few alternatives in the resource-poor setting, clinicians managing patients with severe malaria must be cautious using the physical examination to guide fluid resuscitation. All patients in this series were hypovolaemic on enrolment and, with almost 90% having severe metabolic acidosis and over a third with significant acute kidney injury (AKI), these patients represented the population most likely to benefit from rehydration
Summary
Adults with severe malaria frequently require intravenous fluid therapy to restore their circulating volume. The FrankStarling principle dictates that the cardiac output will fall, reducing tissue perfusion and potentially exacerbating the metabolic acidosis and acute kidney injury (AKI) that are strong predictors of mortality [2,3]. If a patient is volume responsive, fluid loading increases stroke volume and cardiac output and oxygen delivery to tissues. Adults with severe malaria have a generalized increase in vascular permeability which is important in the lungs where pulmonary oedema can occur rapidly, unpredictably, and is frequently fatal [8,9,10]. The hazards of fluid loading have been demonstrated recently in African children with severe malaria, with mortality substantially higher in the patients receiving liberal resuscitation than in those receiving standard maintenance therapy [11]. Finding a balance between over- and under-hydration is challenging for the clinician managing severe malaria
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