Correspondence
| 437
Managing malaria in the intensive care unit J. Gomez-Junyent*, M. Lozano, J. Cid and J. Muñoz Barcelona, Spain *E-mail: [email protected]
patients not receiving exchange transfusion and the exchanged volume was not provided by the authors. Whether an automated RBC exchange could significantly contribute to parasite clearance in patients treated with artesunate remains unknown. Despite all these uncertainties, physicians managing malaria in the intensive care unit should be aware that automated RBC exchange may be an effective and safe adjunctive treatment to artesunate in those patients with severe malaria and high parasitaemia.
Declaration of interest None declared.
References 1. Marks M, Gupta-Wright A, Doherty JF, Singer M, Walker D. Managing malaria in the intensive care unit. Br J Anaesth 2014; 113: 910–21 2. Schwartz J, Winters JL, Padmanabhan A, et al. Guidelines on the use of therapeutic apheresis in clinical practice-evidence-based approach from the Writing Committee of the American Society for Apheresis: the sixth special issue. J Clin Apher 2013; 28: 145–284 3. Auer-Hackenberg L, Winkler S, Graninger W, Worel N, Ramharter M. Current evidence and future of automated erythrocyte exchange in the treatment of severe malaria. Wien Klin Wochenschr 2012; 124(Suppl 3): 23–6 4. Auer-Hackenberg L, Staudinger T, Bojic A, et al. Automated red blood cell exchange as an adjunctive treatment for severe Plasmodium falciparum malaria at the Vienna General Hospital in Austria: a retrospective cohort study. Malar J 2012; 11: 158 5. Kreeftmeijer-Vegter AR, van Genderen PJ, Visser LG, et al. Treatment outcome of intravenous artesunate in patients with severe malaria in the Netherlands and Belgium. Malar J 2012; 11: 102 6. Kreeftmeijer-Vegter AR, Melo Mde M, de Vries PJ, Koelewijn R, van Hellemond JJ, van Genderen PJ. Manual blood exchange transfusion does not significantly contribute to parasite clearance in artesunate-treated individuals with imported severe Plasmodium falciparum malaria. Malar J 2013; 12: 115 doi:10.1093/bja/aew008
Salt at fault? D. J. Bell* and J. Radhakrishnan Chelmsford, UK *E-mail: [email protected]
Editor—We read with interest the recent retrospective cohort analysis by Klinck and colleagues1, investigating the impact
of perioperative sodium changes in a high-risk population. They note an increased mortality risk with changes in sodium
Downloaded from http://bja.oxfordjournals.org/ at Flinders University of South Australia on February 14, 2016
Editor—We read with much interest the comprehensive review of Marks and colleagues1 about the management of malaria in the intensive care unit. The authors briefly describe the conflicting evidence for the use of whole blood exchange transfusion in severe malaria. However, the authors fail to explain the existing reports of apheresis techniques for treating severe malaria patients. Automated red blood cells (RBC) exchange, where infected RBC from the patients are removed and replaced by donor’s RBC units using blood separators, has been used in patients with severe malaria, generally with successful outcomes. A single two-volume RBC exchange (the equivalent to 14 RBC units) can reduce the fraction of remaining infected patient RBC to roughly 10–15% of the original.2 Automated RBC exchange is considered to be safer than whole blood exchange transfusion, as it could reduce the risk of fluid overload and associated infections. Auer-Hackenberg and colleagues3 reviewed the existing reports and case series of the use of RBC exchange in the treatment of severe malaria. They found that 37 patients had received RBC exchange as an adjunctive therapy for severe malaria, of which none died. Interestingly, the parasitaemia dramatically decreased from a median of 30% at admission or before the procedure, to 2.7% after the RBC exchange. The same group had previously reported their experience with RBC exchange in five patients with severe malaria and found no related adverse events with the procedure.4 It seems unlikely, however, that in the next few years the scientific community will be able to collect evidence of RBC exchange from well-performed, controlled, randomized clinical trials. The progressive increase in the availability of artesunate, which has shown to rapidly clear high parasitaemia in severe malaria,5 could limit the use of RBC exchange. Actually, parasite clearance times were not found to differ substantially in patients with severe malaria, who were treated with parenteral antimalarials and manual blood exchange transfusion compared with those who were treated with antimalarials alone, as reported by Kreeftmeijer-Vegter and colleagues.6 It should be mentioned that, in this study, patients receiving manual blood exchange transfusion presented with more severe disease (including significantly higher parasitaemia), as compared with malaria
| 437
Managing malaria in the intensive care unit J. Gomez-Junyent*, M. Lozano, J. Cid and J. Muñoz Barcelona, Spain *E-mail: [email protected]
patients not receiving exchange transfusion and the exchanged volume was not provided by the authors. Whether an automated RBC exchange could significantly contribute to parasite clearance in patients treated with artesunate remains unknown. Despite all these uncertainties, physicians managing malaria in the intensive care unit should be aware that automated RBC exchange may be an effective and safe adjunctive treatment to artesunate in those patients with severe malaria and high parasitaemia.
Declaration of interest None declared.
References 1. Marks M, Gupta-Wright A, Doherty JF, Singer M, Walker D. Managing malaria in the intensive care unit. Br J Anaesth 2014; 113: 910–21 2. Schwartz J, Winters JL, Padmanabhan A, et al. Guidelines on the use of therapeutic apheresis in clinical practice-evidence-based approach from the Writing Committee of the American Society for Apheresis: the sixth special issue. J Clin Apher 2013; 28: 145–284 3. Auer-Hackenberg L, Winkler S, Graninger W, Worel N, Ramharter M. Current evidence and future of automated erythrocyte exchange in the treatment of severe malaria. Wien Klin Wochenschr 2012; 124(Suppl 3): 23–6 4. Auer-Hackenberg L, Staudinger T, Bojic A, et al. Automated red blood cell exchange as an adjunctive treatment for severe Plasmodium falciparum malaria at the Vienna General Hospital in Austria: a retrospective cohort study. Malar J 2012; 11: 158 5. Kreeftmeijer-Vegter AR, van Genderen PJ, Visser LG, et al. Treatment outcome of intravenous artesunate in patients with severe malaria in the Netherlands and Belgium. Malar J 2012; 11: 102 6. Kreeftmeijer-Vegter AR, Melo Mde M, de Vries PJ, Koelewijn R, van Hellemond JJ, van Genderen PJ. Manual blood exchange transfusion does not significantly contribute to parasite clearance in artesunate-treated individuals with imported severe Plasmodium falciparum malaria. Malar J 2013; 12: 115 doi:10.1093/bja/aew008
Salt at fault? D. J. Bell* and J. Radhakrishnan Chelmsford, UK *E-mail: [email protected]
Editor—We read with interest the recent retrospective cohort analysis by Klinck and colleagues1, investigating the impact
of perioperative sodium changes in a high-risk population. They note an increased mortality risk with changes in sodium
Downloaded from http://bja.oxfordjournals.org/ at Flinders University of South Australia on February 14, 2016
Editor—We read with much interest the comprehensive review of Marks and colleagues1 about the management of malaria in the intensive care unit. The authors briefly describe the conflicting evidence for the use of whole blood exchange transfusion in severe malaria. However, the authors fail to explain the existing reports of apheresis techniques for treating severe malaria patients. Automated red blood cells (RBC) exchange, where infected RBC from the patients are removed and replaced by donor’s RBC units using blood separators, has been used in patients with severe malaria, generally with successful outcomes. A single two-volume RBC exchange (the equivalent to 14 RBC units) can reduce the fraction of remaining infected patient RBC to roughly 10–15% of the original.2 Automated RBC exchange is considered to be safer than whole blood exchange transfusion, as it could reduce the risk of fluid overload and associated infections. Auer-Hackenberg and colleagues3 reviewed the existing reports and case series of the use of RBC exchange in the treatment of severe malaria. They found that 37 patients had received RBC exchange as an adjunctive therapy for severe malaria, of which none died. Interestingly, the parasitaemia dramatically decreased from a median of 30% at admission or before the procedure, to 2.7% after the RBC exchange. The same group had previously reported their experience with RBC exchange in five patients with severe malaria and found no related adverse events with the procedure.4 It seems unlikely, however, that in the next few years the scientific community will be able to collect evidence of RBC exchange from well-performed, controlled, randomized clinical trials. The progressive increase in the availability of artesunate, which has shown to rapidly clear high parasitaemia in severe malaria,5 could limit the use of RBC exchange. Actually, parasite clearance times were not found to differ substantially in patients with severe malaria, who were treated with parenteral antimalarials and manual blood exchange transfusion compared with those who were treated with antimalarials alone, as reported by Kreeftmeijer-Vegter and colleagues.6 It should be mentioned that, in this study, patients receiving manual blood exchange transfusion presented with more severe disease (including significantly higher parasitaemia), as compared with malaria
