XIV · Critical appraisal — practices worth questioning Severe Falciparum Malaria14 / 18
Controversies & low-value practices.
Exchange transfusion
Not recommendedPractice: Sometimes offered for parasitaemia >30%
Riddle 2002 meta + WHO 2024: no mortality benefit; resource-intensive; harms (line, transfusion, delay to artesunate).
Adjunctive steroids
ContraindicatedPractice: Tempting in cerebral malaria
Warrell 1982 SNAP: prolonged coma. No subsequent RCT has reversed this — practice persists by default, not evidence.
Liberal fluid resuscitation
HarmfulPractice: 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 analogyPractice: 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 G6PDPractice: P. vivax/ovale only — not falciparum
Falciparum has no hypnozoite stage — primaquine adds nothing and risks haemolysis if G6PD-deficient.
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