title: Outcome of life-threatening malaria in African children requiring endotracheal intubation.
abstract: BACKGROUND
  Little is known about children undergoing critical care for malaria. The purpose of this survey was to evaluate the outcome in African children requiring endotracheal intubation for life-threatening malaria.
  
  
  METHODS
  All children with a primary diagnosis of severe malaria (2000 WHO definition) requiring endotracheal intubation, hospitalised over a five-year period, within a tertiary-care hospital in Dakar, Senegal, were enrolled in a retrospective cohort study.
  
  
  RESULTS
  83 consecutive patients were included (median PRISM h24 score: 14; IQR: 10-19, multiple organ dysfunctions: 91.5%). The median duration of ventilation was 36 hrs (IQR: 4-72). Indications for intubation were deep coma (Glasgow score </=7, n = 16), overt cortical or diencephalic injury, i.e, status epilepticus/decorticate posturing (n = 20), severe brainstem involvement, i.e., decerebrate posturing/opisthotonus (n = 15), shock (n = 15), cardiac arrest (n = 13) or acute lung injury (ALI) (PaO2/FiO2 <300 Torr, n = 4). Death occurred in 50 cases (case fatality rate (CFR), 60%) and was associated with multiple organ dysfunctions (median PELODh24 scores: 12.5 among non-survivors versus 11 among survivors, p = 0.02). Median PRISMh24 score was significantly lower when testing deep coma against other indications (10 vs 15, p < 0.001), ditto for PELODh24 score (2.5 vs 13, p = 0.02). Multivariate analysis identified deep coma as having a better outcome than other indications (CFR, 12.5% vs 40.0 to 93.3%, p < 0.0001). Decerebrate posturing/opisthotonus (CFR 73.3%, adjusted relative risk (aRR) 10.7, 95% CI 2.3-49.5) were associated with a far worse prognosis than status epilepticus/decorticate posturing (CFR 40.0%, aRR 5.7, 95% CI 1.2-27.1). Thrombocytopaenia (platelet counts <100,000/mm3) was associated with death (aRR 2.6, 95% CI 1.2-5.8) and second-line anticonvulsant use (clonazepam or thiopental) with survival (aRR 0.4, 95% CI 0.2-0.9). Complications, mostly nosocomial infections (n = 20), ALI/ARDS (n = 9) or sub-glottic stenosis (n = 3), had no significant prognostic value.
  
  
  CONCLUSIONS
  In this study, the outcome of children requiring intubation for malaria depends more on clinical presentation and progression towards organ failures than on critical care complications per se. In sub-Saharan Africa, mechanical ventilation for life-threatening childhood malaria is feasible, but seems unlikely to dramatically improve the prognosis.
authors.affiliation: Department of Paediatrics, Hôpital Principal, Dakar, Senegal. p.gerardin@ch-sudreunion.fr <p.gerardin@ch-sudreunion.fr>
authors.forename: Patrick
authors.initials: P
authors.lastname: Gérardin
authors.forename: Christophe
authors.initials: C
authors.lastname: Rogier
authors.forename: Amadou S
authors.initials: AS
authors.lastname: Ka
authors.forename: Philippe
authors.initials: P
authors.lastname: Jouvencel
authors.forename: Bakary
authors.initials: B
authors.lastname: Diatta
authors.forename: Patrick
authors.initials: P
authors.lastname: Imbert
mesh_terms: D002648:Child; D002673:Child, Hospitalized; D002675:Child, Preschool; D015331:Cohort Studies; D003128:Coma; D005260:Female; D006306:Health Surveys; D006801:Humans; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data*; D053208:Kaplan-Meier Estimate; D016778:Malaria, Falciparum / Q000150:complications* / Q000401:mortality; D008297:Male; D009026:Mortality; D009102:Multiple Organ Failure; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012306:Risk; D012675:Senegal / Q000453:epidemiology; D012720:Severity of Illness Index; D013921:Thrombocytopenia; D016896:Treatment Outcome