Deck overview

Severe Falciparum Malaria.

18 slides · CICM Fellowship Masterclass · 2026

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CICM Fellowship Masterclass · 2026

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The Returned
Traveller.

Severe Falciparum Malaria

Recognition · Resuscitation · Advanced ICU Management — a case-based fellowship masterclass.

Dr Timothy Chimunda FCICM

Clinical Director ICU · NWRH

I · Session Overview

Severe Falciparum Malaria02 / 18

Learning
objectives.

By the end of this session you will be able to —

Distinction territory

Recognise delayed post-artesunate haemolysis in patients who appear to have recovered.

Severe malaria within minutes of presentation

Uncomplicated from severe malaria — WHO criteria

Evidence-based ICU management immediately

Modern antimalarial therapy correctly

Multi-organ failure of falciparum malaria

Common CICM examination pitfalls

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

02Learning Objectives

II · 0200 hrs · Emergency Department

Severe Falciparum Malaria03 / 18

The patient arrives.

Chief complaint

"He doesn't make sense anymore."

— wife at triage

Symptoms · 4 days

Fever — high, spiking

Rigors — shaking chills

Headache · Vomiting — severe, persistent

Lethargy → confusion

Initial observations

CRT 5 s — circulatory compromise. Act now.

"Geography is the most important laboratory investigation."

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

03Patient Arrives

III · Audience Question 1

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Immediate priorities?

Simultaneous assessment and resuscitation

Activate immediately — don't wait

Geography is the key diagnostic clue

Before antibiotics

Thick + thin films

Request immediately — gold standard

Rapid antigen test

Lactate · ABG · Glucose

Severity markers

Early ICU referral

Do not delay escalation

Consider VHF — Uganda exposure

Differential — febrile returned traveller

P. falciparum malaria

Uganda + no prophylaxis — most likely

Viral haemorrhagic fever

Ebola / Marburg — isolate until excluded

NS1 antigen · rash · thrombocytopenia

Rose spots · relative bradycardia

Water exposure · uveitis · Weil's

Eschar · tick exposure · serology

Bacterial meningitis

CSF · neck stiffness · photophobia

Acute HIV seroconversion

Lymphadenopathy · screen serology

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

04Immediate Priorities

IV · Laboratory results

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Results arrive.

Platelets39 ×10⁹/L ↓↓

Creatinine186 µmol/L ↑

Bilirubin88 µmol/L ↑↑

Lactate5.9 mmol/L ↑↑

Glucose2.2 mmol/L ↓

HCO₃14 mmol/L ↓

Base excess−11

Microbiologist phones

Thick film positive — P. falciparum

Parasitaemia 7%

Audience Q2 · Interactive poll

Does this patient already meet WHO criteria for severe malaria?

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

05Results Arrive

V · WHO 2024 — know these cold

Severe Falciparum Malaria06 / 18

Severity criteria.

Examiners expect WHO criteria verbatim — not just a list of organ failures. Know the thresholds.

Impaired consciousness (GCS <15) · coma (<11) · seizures ≥2/24h · prostration

Pulmonary oedema · ARDS · respiratory distress · SpO₂ <92% RA

Cardiovascular03

Shock · SBP <80 mmHg · impaired perfusion · CRT >3 s

AKI · creatinine >265 µmol/L · haemoglobinuria · oliguria

Haematological05

Severe anaemia Hb <70 g/L · DIC · thrombocytopenia

Glucose <2.2 · pH <7.25 · HCO₃ <15 · lactate >5

Jaundice + organ dysfunction · bilirubin >50 µmol/L

Parasitological08

Hyperparasitaemia · >5% non-immune · >10% any patient

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

06WHO Severity Criteria

VI · Treatment · Audience Q3

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Why artesunate changed everything.

First-line · Severe malaria

2.4 mg/kg at 0 h · 12 h · 24 h — then daily

Do not wait for species confirmation in severe disease.

quinine mortality

mortality reduction

Advantages over quinine

Rapid parasite clearance — kills all life-cycle stages

Lower mortality — 22.5% RRR (AQUAMAT)

Less hypoglycaemia — no insulin stimulation

Better cerebral outcomes — reduced complications

IV bioavailability in critically ill patients

Oral follow-on — artemether-lumefantrine ACT × 3 d

Listing quinine as first-line for severe malaria in 2026 costs marks. Quinine is second-line only — when artesunate is unavailable.

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

VII · Case progression

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Four hours later.

0200 — Admission

GCS 13 · BP 84/48 · Temp 39.8° · Parasitaemia 7%. IV artesunate commenced. ICU admission.

GCS 10 · increasing agitation. Noradrenaline 0.05 mcg/kg/min commenced.

GCS falls to 8 · generalised seizure × 1. BP 78/40. Noradrenaline escalated.

Intubated · ventilated · bilateral CXR infiltrates. FiO₂ 0.70 · PEEP 12 · P/F 110.

Cerebral malaria — pathophysiology

P. falciparum in RBCs

↓ Cytoadherence via PfEMP1

↓ Endothelial activation (ICAM-1)

↓ Microvascular obstruction

↓ Brain oedema + coma

Steroids are contraindicated in cerebral malaria — the SNAP trial showed increased coma duration and GI complications.

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

08Four Hours Later

VIII · ICU management

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Multi-system organ support.

Deaths in severe malaria are caused by multi-organ failure, not parasite burden. ICU support saves the patient — the drug clears the parasite.

Lung-protective

B · Ventilation

· TV 6 mL/kg IBW · Plateau ≤30 cmH₂O
· PEEP 12 · FiO₂ to SpO₂ ≥95%
· Prone if P/F <150 · ECMO last resort

C · Circulation

· Noradrenaline first-line · MAP ≥65
· Arterial line essential
· Conservative fluids — FEAST: boluses kill

D · Artesunate

· 2.4 mg/kg · 0 h / 12 h / 24 h / daily
· Repeat parasitaemia 12-hourly
· Switch to oral ACT when tolerating

· Hourly monitoring — mandatory
· Target 5–10 mmol/L
· Treat: 50 mL 50% dextrose IV stat

· K⁺ 6.2 → urgent CRRT now
· Early CVVHDF for AKI
· Avoid nephrotoxins · protect tubules

· IV lorazepam first-line
· Levetiracetam if recurrent
· Steroids CONTRAINDICATED — SNAP

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

09ICU Multi-Organ Support

IX · Overnight · respiratory failure

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Ventilator data.

P/F ratio · first 24 hBerlin threshold for severe ARDS = 100

Malaria-ARDS — why

Sequestration — parasitised RBCs adhere to pulmonary endothelium → microvascular obstruction

Cytokine storm — TNF-α, IL-1, IL-6 → alveolar capillary leak

Paradox after treatment — ARDS often worsens 24–48 h post-artesunate (parasite lysis)

Conservative fluids — aggressive resus worsens oedema (FEAST)

Prone if P/F <150 for ≥12 h — standard ARDS bundle

ECMO — last resort for refractory ARDS

★ Distinction point

ARDS often worsens after artesunate initiation. This is expected — parasite lysis releases inflammatory mediators. Continue treatment; escalate respiratory support.

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

10Ventilator Data (ARDS)

X · Day 2 · Renal failure

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Creatinine trajectory.

Creatinine µmol/LCRRT commenced Day 2

⚠ Trap 1 — Exchange transfusion

No routine role. WHO and CDC do not recommend it. Riddle 2002 meta-analysis: no mortality benefit. Candidates who advocate it lose marks.

⚠ Trap 2 — Recurrent hypoglycaemia

Parasites consume glucose · reduced gluconeogenesis · quinine stimulates insulin. Hourly glucose is mandatory.

⚠ Trap 3 — Steroids in cerebral malaria

SNAP trial (1982): dexamethasone increased coma duration and GI complications. Never use.

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

11Creatinine Trajectory

XI · Day 4 · Apparent recovery

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The patient wakes.

Patient says: "I feel well. Can I go home?"

★ Distinction territory

Delayed post-artesunate haemolysis.

Volunteering this in a viva impresses examiners — most candidates omit it entirely.

Timing1–3 weeks after IV artesunate completion

MechanismSpleen pits ring stages → parasitised RBCs re-enter circulation → later haemolysed

IncidenceUp to 25% with hyperparasitaemia (>10% RBCs)

FeaturesFalling Hb · jaundice · dark urine · ↑ LDH · ↑ bilirubin · ↑ reticulocytes

MonitoringWeekly FBC · LDH · bilirubin · reticulocytes × 4 weeks

ManagementSupportive — transfuse if Hb <70 g/L or symptomatic

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

12Recovery + Delayed Haem.

XIII · Critical appraisal — what does the evidence actually say?

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The trials we quote — and their limits.

1,461 adults (SE Asia)

Artesunate ↓ mortality 35% vs quinine (15% vs 22%)

RCT · open-label · single-region

5,425 children (Africa)

Artesunate ↓ mortality 22.5% RRR (8.5% vs 10.9%)

RCT · large · external validity strong

3,141 children (Africa)

Fluid boluses ↑ 48-h mortality (RR 1.45)

RCT · resource-limited · no ICU access

8 RCTs · 1,938 pts

Exchange transfusion: no mortality benefit

Meta-analysis · heterogeneous · old data

100 cerebral malaria

Dexamethasone prolonged coma, no survival benefit

Small RCT · never repeated · still cited

Artesunate is the only intervention with high-quality mortality evidence in severe malaria. Most other ICU practices — fluids, RRT timing, ventilation strategy, exchange transfusion — are extrapolated from sepsis/ARDS literature, not malaria-specific RCTs.

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

13Critical Appraisal · Evidence

XIV · Critical appraisal — practices worth questioning

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Controversies & low-value practices.

Exchange transfusion

Not recommended

Practice: Sometimes offered for parasitaemia >30%

Riddle 2002 meta + WHO 2024: no mortality benefit; resource-intensive; harms (line, transfusion, delay to artesunate).

Adjunctive steroids

Contraindicated

Practice: Tempting in cerebral malaria

Warrell 1982 SNAP: prolonged coma. No subsequent RCT has reversed this — practice persists by default, not evidence.

Liberal fluid resuscitation

Practice: Reflex sepsis-style 30 mL/kg bolus

FEAST signal + pulmonary capillary leak in malaria. Use small aliquots, lactate trends, dynamic measures.

Practice: Initiate on AKI + acidosis or K⁺ >6

No malaria-specific trial. STARRT-AKI/AKIKI suggest no benefit to 'very early' RRT — use standard ICU triggers.

Prone + low-VT ventilation

Apply by analogy

Practice: Standard ARDS bundle if P/F <150

PROSEVA/ARMA enrolled few malaria patients — extrapolation is defensible but not RCT-proven in this population.

Primaquine for radical cure

Don't forget G6PD

Practice: P. vivax/ovale only — not falciparum

Falciparum has no hypnozoite stage — primaquine adds nothing and risks haemolysis if G6PD-deficient.

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

14Critical Appraisal · Controversies

XV · Critical appraisal — what we still don't know

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Evidence gaps & where the field is moving.

No adult RCT in HIC ICUs

AQUAMAT/SEAQUAMAT enrolled SE Asian/African populations. Extrapolation to ventilated, RRT-supported HIC patients is implicit.

Optimal artesunate dosing

2.4 mg/kg fixed dose may under-dose obese patients and small children. Pop-PK suggests weight-banded regimens — not yet adopted.

Delayed post-artesunate haemolysis

Mechanism (pitting of once-infected RBCs) understood; predictors and prophylaxis not. No trial of prophylactic transfusion vs surveillance.

CRRT vs IHD timing

No malaria-specific data. Practice extrapolated from septic AKI trials with different physiology (haemoglobinuria, intravascular haemolysis).

Resistance surveillance

Kelch13 mutations now in East Africa (Uganda, Rwanda). Artesunate monotherapy failure rates rising — combination ACTs essential post-IV phase.

Adjunctive therapies

Statins, NO donors, sevuparin, rosiglitazone — all phase II signals, no phase III. Active area; nothing ready for the bedside.

Examiner framing

"Demonstrate that you can cite the trial, name its limitation, and defend your bedside choice when the evidence is thin."

— how distinction candidates are separated from pass candidates.

Three sentences that score

"The mortality evidence rests on AQUAMAT and SEAQUAMAT — both open-label, both outside HIC ICUs."
"FEAST cannot be applied verbatim to a ventilated adult, but the signal of harm from reflex bolusing is real."
"For exchange transfusion and steroids, absence of benefit in available trials outweighs mechanistic appeal."

Critical appraisal isn't a separate section of the viva — it's the texture of every good answer.

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

15Critical Appraisal · Gaps

XVI · Fellowship viva — rapid-fire

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Click each card
for the model answer.

8 stations · 90 s each

01Thick vs thin blood films+

02WHO criteria for severe malaria+

03Management of cerebral malaria+

04Why ARDS worsens after treatment+

05Management of shock+

06Delayed haemolysis+

07Exchange transfusion — not recommended+

08IV → oral transition+

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

16Viva Stations

XVII · CICM examiner pearls

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Top 10 — what the
examiners want.

Never delay artesunate

Start immediately — don't wait for species ID

Films are gold standard

Thick + thin · ×3 · 12 h apart

Severe = organ dysfunction

WHO criteria verbatim — not just parasitaemia

Early airway control

GCS ≤8 → RSI and intubate

Conservative fluids

FEAST trial — boluses increase mortality

Repeat parasite counts

12-hourly until clearance confirmed

Mandatory throughout ICU admission

MOF = ICU syndromes

Ventilate · CRRT · vasopressors

Exchange Tx — not routine

No evidence · will cost marks

Delayed haemolysis

4-week monitoring post-artesunate

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

17Top 10 Pearls

XVIII · Take-home messages

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Every febrile returned traveller — especially sub-Saharan Africa

Diagnose rapidly

Thick/thin films · RDT · PCR — treat on strong clinical suspicion

Start artesunate immediately

Do not delay. Do not use quinine first-line.

Organ support saves lives

ICU management prevents death — the drug clears the parasite

Recovery ≠ discharge

Monitor delayed haemolysis × 4 weeks post-artesunate

AQUAMATDondorp et al. Lancet 2010;376:1647–57 — artesunate vs quinine

SEAQUAMATDondorp et al. Lancet 2005;366:717–25 — first adult evidence

WHO 2024Living guideline — current treatment recommendations

FEASTMaitland et al. NEJM 2011;364:2483–95 — fluid bolus harm

Marks et al.Br J Anaesth 2014;113(6):910–921 — managing malaria in ICU

Riddle et al.Clin Infect Dis 2002;34:1192–8 — exchange transfusion meta

Dr Timothy Chimunda FCICM

Clinical Director ICU · NWRH · Innovate Critical Care Consultancy

CICM Fellowship Masterclass · 2026Dr Timothy Chimunda FCICM

18Take-Home + References