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Malaria Mortality Risk Prediction

Purpose: To evaluate the risk of mortality in a patient with severe malaria using the number of organ failures and the APACHE II score.

Description

Lichtman et al identified the risk of mortality in patients with severe malaria based on measures of organ dysfunction at admission to the intensive care unit (ICU). This can help identify patients who may require more aggressive management. The authors are from the State Hospital in Windhoek, Namibia.


Organ systems:

(1) respiratory

(2) cardiac

(3) renal

(4) cerebral

(5) liver

(6) hematologic

 

Organ System

Criteria for Organ Failure On Admission

respiratory

mechanical ventilation AND alveolar-arterial oxygen gradient > 100 mm Hg when on ventilatory support

cardiac

mean arterial pressure < 60 mm Hg with an adequate filling pressure (by central venous pressure or pulmonary capillary wedge pressure)

renal

urine output < 12 mL/kg per day OR serum creatinine > 150 µmol/L (1.7 mg/dL)

cerebral

unrousable coma OR grand mal convulsions not caused by hypoxia, cerebral hypoperfusion, or abnormal chemistries

liver

total bilirubin > 2 times the upper limit of normal AND SGPT (ALT) > 2 times the upper limit of normal AND prothrombin index < 60%

hematologic

platelet count < 50,000 per µL OR DIC OR severe hemolysis

 

where:

• The prothrombin index is rarely measured in the US. It measures the percent of the normal level of prothrombin complex that is present. According to Schulman (New Engl J Med. 2003; 349: 675-683, Figure 1 page 680; see Chapter 4) an INR of 1.0 indicates 100% and an INR of 1.4-1.6 indicates 40%. I will use an INR of 1.2 to indicate 60% prothrombin activity.

 

The presence of >= 3 organ failures was associated with a high mortality rate. Most of the patients who died had respiratory and/or renal failure.

 

In addition, the authors correlated the APACHE II score with mortality.

 

Apache II Score

Mortality Risk

< 17

none

17 - 30

low to moderate

> 30

high

 

Limitations:

• The study was done at the only ICU in Namibia, which had only 8 beds. Survival would probably be better in an ICU at a major medical center.


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Specialty

Objective

ICD-10