Table 6.

Intraoperative anesthetic goals in patients with malaria

Anesthesia	Goals	Suggested management strategies
Induction	Hemodynamically stable induction without increased CBF Avoid surges in ICP and hypercapnia	Propofol Avoid Ketamine Ensure full neuromuscular blockade prior to intubation Obtund the autonomic response to intubation Start ventilation as soon as intubation is confirmed
Maintenance	Avoid cerebral vasodilation /raised ICP	Sevoflurane/Propofol (less CBF increase with Propofol) Maintain normocapnia 15° head-up position Avoid endotracheal tube ties Regular assessment of pupils
	Lung protective ventilation strategy	TV 6 mL·kg−1 Application of PEEP Limit plateau pressures < 30 cm H2O38
	Avoid fluid overload	TEE/CVP guided fluid therapy Early use of inotropes preferential to excessive fluid boluses18
	Avoid hypoglycemia	10% Dextrose as maintenance infusion Measure blood glucose twice hourly21
	Appropriate transfusion of blood products	Blood transfusion if hemoglobin < 7 g·dL−1 or hematocrit < 20% Platelet transfusion for surgery if platelets < 50 × 109·L−1
Extubation	Safe and appropriate extubation	Ensure resolution of neuromuscular blockade Prolonged blockade in the presence of quinine may require postoperative ventilation Minimize increases in ICP on extubation Avoid excessive use of sedative drugs Short-acting opioids preferred

CBF = cerebral blood flow; ICP = intracranial pressure; TV = tidal volume; PEEP = positive end expiratory pressure; TEE = transesophageal echocardiography; CVP = central venous pressure