title: Central venous catheter use in severe malaria: time to reconsider the World Health Organization guidelines?
abstract: BACKGROUND
  To optimize the fluid status of adult patients with severe malaria, World Health Organization (WHO) guidelines recommend the insertion of a central venous catheter (CVC) and a target central venous pressure (CVP) of 0-5 cmH2O. However there are few data from clinical trials to support this recommendation.
  
  
  METHODS
  Twenty-eight adult Indian and Bangladeshi patients admitted to the intensive care unit with severe falciparum malaria were enrolled in the study. All patients had a CVC inserted and had regular CVP measurements recorded. The CVP measurements were compared with markers of disease severity, clinical endpoints and volumetric measures derived from transpulmonary thermodilution.
  
  
  RESULTS
  There was no correlation between the admission CVP and patient outcome (p = 0.67) or disease severity (p = 0.33). There was no correlation between the baseline CVP and the concomitant extravascular lung water (p = 0.62), global end diastolic volume (p = 0.88) or cardiac index (p = 0.44). There was no correlation between the baseline CVP and the likelihood of a patient being fluid responsive (p = 0.37). On the occasions when the CVP was in the WHO target range patients were usually hypovolaemic and often had pulmonary oedema by volumetric measures. Seven of 28 patients suffered a complication of the CVC insertion, although none were fatal.
  
  
  CONCLUSIONS
  The WHO recommendation for the routine insertion of a CVC, and the maintenance of a CVP of 0-5 cmH2O in adults with severe malaria, should be reconsidered.
authors.affiliation: Department of Medicine, Cairns Base Hospital, Queensland, Australia. drjoshhanson@gmail.com
authors.forename: Josh
authors.initials: J
authors.lastname: Hanson
authors.forename: Sophia Wk
authors.initials: SW
authors.lastname: Lam
authors.forename: Sanjib
authors.initials: S
authors.lastname: Mohanty
authors.forename: Shamshul
authors.initials: S
authors.lastname: Alam
authors.forename: Md Mahtab Uddin
authors.initials: MM
authors.lastname: Hasan
authors.forename: Sue J
authors.initials: SJ
authors.lastname: Lee
authors.forename: Marcus J
authors.initials: MJ
authors.lastname: Schultz
authors.forename: Prakaykaew
authors.initials: P
authors.lastname: Charunwatthana
authors.forename: Sophie
authors.initials: S
authors.lastname: Cohen
authors.forename: Ashraf
authors.initials: A
authors.lastname: Kabir
authors.forename: Saroj
authors.initials: S
authors.lastname: Mishra
authors.forename: Nicholas Pj
authors.initials: NP
authors.lastname: Day
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: White
authors.forename: Arjen M
authors.initials: AM
authors.lastname: Dondorp
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001459:Bangladesh; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000706:statistics & numerical data*; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D017408:Guidelines as Topic; D006801:Humans; D007194:India; D016778:Malaria, Falciparum / Q000473:pathology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D014944:World Health Organization; D055815:Young Adult
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