Retrospective Comparison of 2 Management Strategies for Perioperative Malaria Episodes in Pediatric Patients in a Limited-Resource Setting
Authors: Roark Gary L. 
Published: May 2019

BACKGROUND:
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.

METHODS:
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.

RESULTS:
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.

CONCLUSIONS:
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.