XIII · Critical appraisal — what does the evidence actually say? Severe Falciparum Malaria13 / 18
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
Bottom line
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