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Research Article

Assessment of Volume Depletion in Children with Malaria

  • Timothy Planche,

    Affiliations: Department of Cellular and Molecular Medicine, Infectious Diseases, St. George's Hospital Medical School, London, United Kingdom, Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon

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  • Myriam Onanga,

    Affiliation: Département de Parasitologie, Mycologie, et Médecine Tropicale, Faculté de Médecine, Université des Sciences de la Santé, Libreville, Gabon

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  • Achim Schwenk,

    Affiliations: Department of Cellular and Molecular Medicine, Infectious Diseases, St. George's Hospital Medical School, London, United Kingdom, Coleridge Unit, North Middlesex University Hospital, London, United Kingdom

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  • Arnaud Dzeing,

    Affiliation: Département de Parasitologie, Mycologie, et Médecine Tropicale, Faculté de Médecine, Université des Sciences de la Santé, Libreville, Gabon

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  • Steffen Borrmann,

    Affiliations: Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon, Department of Parasitology, Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany

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  • Jean-François Faucher,

    Affiliation: Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon

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  • Antony Wright,

    Affiliation: Elsie Widdowson Laboratory, Medical Research Council Human Nutrition Research, Cambridge, United Kingdom

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  • Les Bluck,

    Affiliation: Elsie Widdowson Laboratory, Medical Research Council Human Nutrition Research, Cambridge, United Kingdom

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  • Leigh Ward,

    Affiliation: Department of Biochemistry, University of Queensland, St Lucia, Australia

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  • Maryvonne Kombila,

    Affiliation: Département de Parasitologie, Mycologie, et Médecine Tropicale, Faculté de Médecine, Université des Sciences de la Santé, Libreville, Gabon

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  • Peter G Kremsner,

    Affiliations: Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon, Department of Parasitology, Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany

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  • Sanjeev Krishna

    Affiliations: Department of Cellular and Molecular Medicine, Infectious Diseases, St. George's Hospital Medical School, London, United Kingdom, Medical Research Unit, Albert Schweitzer Hospital, Lambaréné, Gabon

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  • Published: October 19, 2004
  • DOI: 10.1371/journal.pmed.0010018

Reader Comments (2)

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Volume status in severe malaria: no evidence provided for the degree of filling of the intravascular compartment

Posted by plosmedicine on 30 Mar 2009 at 23:38 GMT

Author: Kathryn Maitland
Position: Doctor
Institution: The Centre for Geographic Medicine Research, Coast, KEMRI, Kenya, P O Box 230, Kilifi, Kenya
E-mail: kmaitland@kilifi.mimcom.net
Additional Authors: Charles Newton, Kevin Marsh and Michael Levin
Submitted Date: November 08, 2004
Published Date: November 16, 2004
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

The study by Planche et al (1) provides important new information addressing intracellular volume depletion in children with severe childhood malaria, but does not address the question of whether intravascular volume depletion (hypovolemic shock) is present. Using sophisticated methodology to determine total body water and extracellular water they demonstrate a 6.7% deficit in total body water and an 11.7% deficit of intracellular water providing an important indication of the volumes of fluid which may be required to optimize hydration. The data however, neither address the degree of filling of the intravascular compartment nor should they be used to answer the question about the state of tissue and organ perfusion.

Indeed, we believe that these new data present no conflict with our previously reported findings. Using methods to study critical illness physiology that are widely employed within pediatric intensive care units for interpretation of circulatory status we have demonstrated evidence for hypovolemia in 53 Kenyan children with severe malaria complicated by metabolic acidosis (2). Our children were younger, had longer capillary refilling times (>3s), lower CVP's (mean 2.9 cm H2O) and higher creatinines (>80micromols/l): all features of compensated hypovolemic shock. Furthermore, hypotension (systolic BP <80mmHg) was present in 44% of children with severe acidosis (base deficit >15). These findings also indicate important baseline differences in two cohorts of children studied.

We agree that reconsideration of guidelines for the acute fluid management is warranted, particularly when current recommendations await an adequate evidence base. Nevertheless, conflicting opinions on the question of volume status in children with severe malaria can only be satisfactorily resolved through prospective randomized trials that include both fluid resuscitation and control groups. While the design and conduct of such trials will involve considerable challenges optimal fluid management will never be resolved on the basis of theoretical consideration alone.

1. Planche T, Onanga M, Schwenk A, Dzeing A, Borrmann S, Faucher JF, Wright A, Bluck L, Ward L, Kombila M, Kremsner PG, Krishna S. Assessment of Volume Depletion in Children with Malaria. Plos Med 2004; 1: e18.

2. Maitland K, Pamba A, Newton CR, Levin M. Response to volume resuscitation in children with severe malaria. Pediatr. Crit. Care Med. 2003; 4: 426-31.

Competing interests declared: none