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Central venous catheter use in severe malaria: time to reconsider the World Health Organization guidelines?

Josh Hanson12*, Sophia WK Lam12, Sanjib Mohanty3, Shamshul Alam4, Md Mahtab Uddin Hasan5, Sue J Lee2, Marcus J Schultz6, Prakaykaew Charunwatthana2, Sophie Cohen7, Ashraf Kabir8, Saroj Mishra3, Nicholas PJ Day29, Nicholas J White29 and Arjen M Dondorp29

Author Affiliations

1 Department of Medicine, Cairns Base Hospital, Queensland, Australia

2 Mahidol Oxford Research Unit, Mahidol University, Bangkok, Thailand

3 Department of Medicine, Ispat General Hospital, Rourkela, India

4 Department of Intensive Care Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh

5 Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh

6 Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

7 Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands

8 Department of Anaesthetics, Cox's Bazar Medical College, Cox's Bazar, Bangladesh

9 Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK

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Malaria Journal 2011, 10:342  doi:10.1186/1475-2875-10-342

Published: 14 November 2011

Abstract

Background

To optimize the fluid status of adult patients with severe malaria, World Health Organization (WHO) guidelines recommend the insertion of a central venous catheter (CVC) and a target central venous pressure (CVP) of 0-5 cmH2O. However there are few data from clinical trials to support this recommendation.

Methods

Twenty-eight adult Indian and Bangladeshi patients admitted to the intensive care unit with severe falciparum malaria were enrolled in the study. All patients had a CVC inserted and had regular CVP measurements recorded. The CVP measurements were compared with markers of disease severity, clinical endpoints and volumetric measures derived from transpulmonary thermodilution.

Results

There was no correlation between the admission CVP and patient outcome (p = 0.67) or disease severity (p = 0.33). There was no correlation between the baseline CVP and the concomitant extravascular lung water (p = 0.62), global end diastolic volume (p = 0.88) or cardiac index (p = 0.44). There was no correlation between the baseline CVP and the likelihood of a patient being fluid responsive (p = 0.37). On the occasions when the CVP was in the WHO target range patients were usually hypovolaemic and often had pulmonary oedema by volumetric measures. Seven of 28 patients suffered a complication of the CVC insertion, although none were fatal.

Conclusion

The WHO recommendation for the routine insertion of a CVC, and the maintenance of a CVP of 0-5 cmH2O in adults with severe malaria, should be reconsidered.