Researchers recommend changes to drip treatment for malaria and dengue fever patients in Africa

Researchers advise against putting malaria and dengue patients on a drip to give them fluids where possible, even though it is recommended in the international treatment guidelines. 

A drip is a small plastic tube with one end inserted directly into a patient’s bloodstream using a needle, and the other end connected to a bag of fluid or medicine, which then “drips” directly into that patient’s bloodstream through the tube.

Malaria and dengue fever are diseases that affect many people in Africa. Doctors are given standard guidelines on how to treat patients, but some doctors have observed that patients in poorer countries respond differently to drip treatment than those in Western countries.

So, in this book chapter, the authors reviewed the current guidelines for managing malaria and dengue fever, and made some recommendations for poor countries.

The authors said doctors needed to test for malaria by checking for the actual disease-causing malaria parasites in the patient’s blood. If parasites are found, patients should be given medication right away.  

They said patients should only be given fluids or medication through a drip if they have lost a lot of blood and their heart is not pumping enough blood. 

They also suggested that if given, doctors should reduce the usual volume in patients who are taking other fluids on the side. They said if patients were unable to eat by themselves, the doctors could start giving them food through feeding tubes only after 2 and a half days.

The authors also said where patients had cerebral malaria that affected the brain, patients should be carefully allowed to get enough air to avoid brain swelling.

The authors said for dengue disease, doctors should not give patients lots of fluid through drips, but if needed it should be done more slowly. They said doctors should be quick to put dengue patients on drip, but should stop when the patient gets better to avoid a condition where the fluids get into the lungs.

They also said if the patient did not bleed, it was not necessary to give them blood. They said large volumes of liquids through a drip should only be given if patients had low blood pressure. They said for patients with less blood but good blood pressure, doctors should not put them on drip.

They also recommended that doctors should not give dengue patients any medicine that reduced swelling.

Doctors should avoid giving patients blood where possible because patients may be allergic and or may be exposed to other disease-causing microorganisms in this way. Doctors should only give blood if the patient lost a lot of blood.

The authors cautioned that sometimes they did not have enough information to make recommendations.

The researchers were from institutions in Uganda, South Africa, Thailand, the UK, the Netherlands, Vietnam, Austria, and India.

Abstract

This chapter summarizes recommendations on important aspects of the management of patients with severe malaria and severe dengue. Severe falciparum malaria requires rapid parasitological diagnosis by microscopy or rapid diagnostic test (RCT) and prompt initiation of parenteral artesunate. Fluid bolus therapy should be avoided in patients without hypotensive shock, and we suggest initial (24 h) crystalloid fluid therapy of 2–4 mL/kg/h, which may subsequently be reduced to 1 mL/kg/h in patients receiving additional fluids, e.g., through enteral tube feeding. In the minority of those patients presenting with hypotensive shock, we suggest fluid bolus therapy (30 mL/kg) with an isotonic crystalloid and early initiation of vasopressor support. Enteral feeding in non-intubated adult patients with cerebral malaria can start after 60 h, to avoid aspiration pneumonia. There are insufficient data to suggest this in pediatric cerebral malaria.

The diagnosis of severe dengue is commonly with a combined dengue antigen (NS1) and antibody RDT. No antiviral treatment is currently available. Dengue shock results from capillary leakage, although hemorrhage or depression of myocardial contractility can contribute. The World Health Organization guidelines recommend restoration of the circulation guided by pulse pressure, capillary refill time, hematocrit, and urine output. Large (>15 mL/kg) rapid (<30 min) fluid boluses should be avoided, but prompt fluid administration with crystalloids is essential and should be restricted as soon as the critical phase is over to avoid pulmonary edema. Corticosteroids are not recommended, neither is platelet transfusion for thrombocytopenia in the absence of active bleeding or other risk factors.

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