The reliability of the physical examination to guide fluid therapy in adults with severe falciparum malaria: an observational studyReportar como inadecuado

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Malaria Journal

, 12:348

First Online: 01 October 2013Received: 05 August 2013Accepted: 20 September 2013


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 identifier: NCT00692627

KeywordsSevere malaria Physical examination Fluid resuscitation  Download fulltext PDF

Autor: Josh Hanson - Sophia WK Lam - Shamsul Alam - Rajyabardhan Pattnaik - Kishore C Mahanta - Mahatab Uddin Hasan - Sanjib Moh


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