From the Department of Anesthesia, Beverly Hospital, Lahey Medical System, Beverly, Massachusetts.
Anesth Analg. 2019 Aug;129(2):515-519. doi: 10.1213/ANE.0000000000004186.
Malaria is a common problem throughout the world, particularly in sub-Saharan Africa, where 90% of all deaths in the world from malaria occur. While many studies on malaria are available in the medical literature, few publications have addressed the problems of managing malaria during surgery and anesthesia. At a newly opened hospital in Niger, we initiated further studies to evaluate our process of managing malaria when we had a number of problems in our first group of pediatric patients having elective cleft lip and palate repairs. Many patients had fevers during and soon after surgery and were found to have clinical malaria, despite recent treatment.
In our first group of 16 patients (group A), 4 initially tested positive for malaria by light microscopy and were treated before arrival at our hospital. On arrival at our hospital, we retested all the patients for malaria. Three of the original 4 were still positive. Six additional patients also tested positive, for a total of 9 of 16 in group A. Despite treatment, 6 of these 16 patients still had fevers in the operating rooms and postoperative period requiring further treatment for clinical malaria (6/16 or 38% incidence of perioperative malaria; 95% CI, 15%-65%).We then changed our diagnostic and management strategies for subsequent patients: all patients were tested for malaria 3-7 days before surgery at our hospital rather than before arrival. We decided to universally treat all patients coming for surgery for presumed malaria due to the number of problems encountered in the first group and the high prevalence of malaria in our population. We changed the source of the malaria medications used for all subsequent patients. We included rapid diagnostic tests for falciparum and nonfalciparum malaria species.
After the change in protocols, no children in the second group of patients (group B, n = 53) developed clinical malaria or fever during or after surgery (P < .0001, comparing 6/16 vs 0/53, using Fisher exact test). During the first 4 months after the implementation of rapid diagnostic tests for malaria testing, we tested 283 patients, of whom 73 were found to be positive for malaria by light microscopy and/or rapid diagnostic test. Of the 73 malarias, 24.6% were nonfalciparum malarias (95% CI, 14.7%-34.5%), much higher than the 1%-5% incidence that international and local health officials told us to expect.
Pediatric patients in many areas of the world often present with a high risk for malaria in the perioperative time frame. Treatment with artemisinin-based therapy 3-7 days before elective surgeries may be an effective method to reduce the risks of febrile episodes and clinical malaria during and after surgery in areas of high transmission. However, these results may be limited by (1) the presence of nonfalciparum malarias, some of which may require prolonged treatment for hepatic cryptogenic malaria; (2) the potential for complications related to counterfeit medications; and (3) international efforts at malaria eradication, especially when considering the use of malaria medications that have the potential to develop drug resistance.
疟疾是一个全球性的常见问题，特别是在撒哈拉以南非洲地区，全世界 90%的疟疾死亡病例都发生在这里。虽然医学文献中有许多关于疟疾的研究，但很少有出版物涉及手术和麻醉期间管理疟疾的问题。在尼日尔新开的一家医院，我们在第一批接受择期唇腭裂修复术的儿科患者中遇到了一些问题，因此我们进一步开展了研究，以评估我们管理疟疾的流程。许多患者在手术期间和手术后不久出现发热，尽管最近进行了治疗，仍被发现患有临床疟疾。
在我们的第一批 16 名患者（A 组）中，4 名患者最初通过光学显微镜检测为疟疾阳性，并在抵达我们医院之前接受了治疗。抵达我们医院后，我们重新对所有患者进行了疟疾检测。最初的 4 名患者中有 3 名仍然呈阳性。另外 6 名患者也检测出阳性，A 组共有 9 名患者（占 16 名患者的 56%）。尽管进行了治疗，但这 16 名患者中有 6 名仍在手术室和术后期间发热，需要进一步治疗临床疟疾（6/16 或 38%的围手术期疟疾发生率；95%CI，15%-65%）。因此，我们改变了后续患者的诊断和管理策略：所有患者在抵达我们医院前 3-7 天在医院进行疟疾检测，而不是在抵达前进行。由于第一批患者遇到的问题较多，且我们人群中疟疾的高患病率，我们决定对所有接受手术的患者进行推定疟疾的普遍治疗。我们改变了用于所有后续患者的疟疾药物来源。我们纳入了针对恶性疟原虫和非恶性疟原虫疟疾的快速诊断检测。
在方案改变后，第二组患者（B 组，n=53）在手术期间或之后没有出现临床疟疾或发热（P<.0001，6/16 与 0/53 相比，采用 Fisher 确切概率法）。在实施疟疾快速诊断检测后的头 4 个月，我们检测了 283 名患者，其中 73 名患者通过光学显微镜和/或快速诊断检测被诊断为疟疾阳性。在这 73 例疟疾中，24.6%为非恶性疟原虫疟疾（95%CI，14.7%-34.5%），远高于国际和当地卫生官员告诉我们的 1%-5%的发病率。
世界上许多地区的儿科患者在围手术期通常存在疟疾高风险。在择期手术前 3-7 天使用青蒿素为基础的疗法进行治疗，可能是一种降低手术期间和手术后发热和临床疟疾风险的有效方法，特别是在疟疾高传播地区。然而，这些结果可能受到以下因素的限制：（1）存在非恶性疟原虫疟疾，其中一些可能需要延长治疗时间以治疗肝源性隐源性疟疾；（2）与假冒药物相关的潜在并发症；（3）国际消除疟疾努力，特别是考虑到使用可能产生耐药性的疟疾药物。
