title: Extracorporeal membrane oxygenation for refractory acute respiratory distress syndrome in severe malaria.
abstract: BACKGROUND
  Severe malaria may be complicated by the acute respiratory distress syndrome (ARDS), which is associated with a high mortality. In the present report, a series of three cases of imported malaria complicated by refractory severe ARDS supported with extracorporeal membrane oxygenation (ECMO) is presented.
  
  
  METHODS
  One female and two male adult patients (ages 39 to 53) were included. Two patients had Plasmodium falciparum infection and one patient had Plasmodium vivax and Plasmodium ovale co-infection. Anti-malarial therapy consisted in intravenous quinine (in two patients) and intravenous quinidine (in one patient), plus clindamycin or doxycycline.
  
  
  RESULTS
  Despite lung protective ventilation, a conservative strategy of fluid management, corticosteroids (two patients), prone position (two patients) and inhaled nitric oxide (one patient), refractory severe ARDS supervened (PaO2 to FiO2 ratio 68) and venovenous ECMO was then initiated. In one patient, a bicaval dual-lumen cannula was inserted; in the two other patients, a two-site configuration was used. Two patients survived to hospital-discharge (duration of ECMO support: 8.5 days) and one patient died from nosocomial sepsis and multi-organ failure after 40 days of ECMO support.
  
  
  CONCLUSIONS
  ECMO support allowed adequate oxygenation and correction of hypercapnia under lung protective ventilation, therefore reducing ventilator-induced lung injury. ECMO referral should be considered early in malaria complicated by severe ARDS refractory to conventional treatment.
authors.forename: Carlos
authors.initials: C
authors.lastname: Alves
authors.forename: Jen-Ting
authors.initials: JT
authors.lastname: Chen
authors.forename: Nina
authors.initials: N
authors.lastname: Patel
authors.forename: Darryl
authors.initials: D
authors.lastname: Abrams
authors.forename: Paulo
authors.initials: P
authors.lastname: Figueiredo
authors.forename: Lurdes
authors.initials: L
authors.lastname: Santos
authors.forename: António
authors.initials: A
authors.lastname: Sarmento
authors.forename: José Artur
authors.initials: JA
authors.lastname: Paiva
authors.forename: Matthew
authors.initials: M
authors.lastname: Bacchetta
authors.forename: May-Lin
authors.initials: ML
authors.lastname: Wilgus
authors.forename: Roberto
authors.initials: R
authors.lastname: Roncon-Albuquerque
authors.forename: Daniel
authors.initials: D
authors.lastname: Brodie
mesh_terms: D000328:Adult; D000962:Antimalarials / Q000627:therapeutic use; D015199:Extracorporeal Membrane Oxygenation; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D008288:Malaria / Q000188:drug therapy / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D010961:Plasmodium / Q000302:isolation & purification; D012128:Respiratory Distress Syndrome / Q000469:parasitology* / Q000628:therapy*
chemical_list: D000962:Antimalarials