Any severity criterion with asexual parasites (P. falciparum, and also P. vivax or knowlesi) = severe malaria: IV artesunate 2.4 mg/kg at 0, 12, 24 h then daily, followed by a full oral ACT course, plus glucose monitoring, careful fluids, and organ support.
At the bedside
Timed steps- 1
Smear + RDT
ConfirmParasite count; but treat on clinical grounds if testing is delayed.
- 2
Artesunate
0 h2.4 mg/kg IV (or IM) at 0, 12, 24 h, then daily until oral intake (≥ 24 h), then complete 3-day ACT (+ single-dose primaquine for falciparum per national policy).
- 3
Hourly-4 hourly
GlucoseHypoglycaemia (< 40 mg/dL) is common, especially in pregnancy and with quinine; give dextrose.
- 4
Restrictive
FluidsNo aggressive boluses (FEAST-type harm; ARDS risk); treat hypovolaemia cautiously; early RRT for AKI or severe acidosis.
- 5
Supportive
OtherTransfuse if Hb < 7 g/dL; antibiotics if shock or suspected bacteraemia; treat seizures; no steroids, mannitol or exchange transfusion.
- 6
Late haemolysis
Follow-upHb at day 7, 14 and 28 after artesunate (PADH). Vivax: G6PD test, then primaquine 0.25 mg/kg daily × 14 days for radical cure.
Severe malaria
Artesunate (IV/IM)
- Dose
- 2.4 mg/kg at 0, 12, 24 h, then every 24 h
- Worked example
- 55 kg: 132 mg ≈ 2.2 vials (60 mg); reconstitute each vial with 1 mL bicarbonate + 5 mL saline (10 mg/mL) → 13.2 mL IV
WHO criteria for severe malaria (adults; any one with parasitaemia)
| Feature | Threshold |
|---|---|
| Impaired consciousness | GCS < 11 |
| Prostration | Unable to sit/stand/walk without help |
| Multiple convulsions | > 2 in 24 h |
| Acidosis | Base deficit > 8, HCO3- < 15 mmol/L or lactate ≥ 5 mmol/L |
| Hypoglycaemia | < 40 mg/dL (2.2 mmol/L) |
| Severe anaemia | Hb < 7 g/dL with parasitaemia > 10,000/µL |
| Renal impairment | Creatinine > 3 mg/dL or urea > 20 mmol/L |
| Jaundice | Bilirubin > 3 mg/dL with parasitaemia > 100,000/µL |
| Pulmonary oedema | Radiological, or SpO2 < 92% on air with RR > 30 |
| Significant bleeding | Recurrent/prolonged nose, gum or venepuncture bleeding, haematemesis, melaena |
| Shock | SBP < 80 mmHg with impaired perfusion |
| Hyperparasitaemia | > 10% parasitised red cells |
From WHO severe malaria definitions (WHO malaria guidelines).
References
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Severe malaria
Step 1 of ~6
IV artesunate 2.4 mg/kg 0, 12, 24 h
Based on World Health Organization. Educational use; follow local protocol.
Evidence
- SEAQUAMAT 2005: mortality 15% artesunate vs 22% quinine in adults.
- AQUAMAT 2010: 8.5% vs 10.9% in African children.
🇮🇳 India notes
- Artesunate is supplied by the national programme; severe vivax malaria and mixed infections are increasingly reported. ACT choice differs: AS+SP nationally, artemether-lumefantrine in the north-east.
References
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Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.