DISCUSSION
Magnesium sulfate is frequently utilized to treat eclampsia and
pre-eclampsia during pregnancy as an anticonvulsant [9]. Magnesium
sulfate extensively influences heart, lung, and brain function
[10-12]. Predominantly hypermagnesemia occurs when renal function
decreases or a large quantity of magnesium is loaded [13,14].
Clinical presentation of hypermagnesemia is associated with the serum
magnesium concentration. Nausea, vomiting, bradycardia, and hypotension
take place at the magnesium serum level of 4-7 mEq/L, moreover, loss of
deep tendon reflexes and increased QT interval duration take place at
the serum level of 8-10 mEq/L. Also, comatose, muscle paralysis,
complete AV block, and cardiac arrest take place at serum levels greater
than 12 mEq/L [15,16].
The management of patients with hypermagnesemia would be needed to
eliminate magnesium through renal excretion by high-volume normal saline
infusion and loop diuretic consumption, Because of the specificity of
the loop diuretics which inhibits tubular reabsorption of magnesium in
the thick ascending part of Henle’s loop. For patients with impaired
kidneys or who have the clinical symptoms of hypermagnesemia,
hemodialysis should be considered. In patients with symptoms of
hypermagnesemia, it should be managed with calcium to prevent the
neuromuscular and cardiovascular adverse effects of hypermagnesemia
[17].
a large number of cases of hypermagnesemia were reported in Japan due to
magnesium oxide (MgO) prescription as a laxative in elderly patients
with constipation, most of whom had chronic kidney disease (CKD). In
addition, some of the cases had dementia or cerebrovascular events and
couldn’t express their symptoms, and the magnesium serum concentration
was not examined. All of the cases were treated with fluid infusion
(normal saline) and diuretics except one case that was managed by
continuous hemodiafiltration (CHDF) and after 4 days died at the
hospital [18-23].
In Akbar MIA et al’s study, they reported 19 Mg intoxication
patients in preeclampsia with severe features in women treated with
magnesium sulfate and it was significantly associated with prenatal
death and low Apgar score at 1 and 5 minutes. All of the Mg
intoxications were treated with calcium gluconate immediately in line
with Indonesian national protocol. 3 patients died, whereas, it was not
due to hypermagnesemia events [24].
Another case was reported in 2021, a 34-year-old man reached the
emergency ward after he was found unresponsive in a restaurant, and an
empty bottle of magnesium supplement and ibuprofen was with him. He was
hypotensive and hypothermic. His serum magnesium concentration was 11.7
mEq/L. he was admitted to the intensive care unit and intubated and
intravenous calcium was initiated. Continuous renal replacement therapy
(CRRT) was started for him and serum magnesium level lowered. His
complications in the hospital were extensive. despite various
vasopressors utilized, he was in shock. Abdominal compartment syndrome
needed for bedside laparotomy, aspiration pneumonia, acute respiratory
distress, and disseminated intravascular coagulation (DIC) led to his
family’s decision to transmit him to comfort care, and he died on the
4th day [25].
Our case was an iatrogenic and EMS mistake magnesium sulfate overdose
which was performed continuously for 4 hours of hemodialysis. calcium
gluconate was administrated to protect against cardiac complications.
After hemodialysis, the patients recovered and then extubated. during
treatment in the hospital, she showed hypocalcemia, hypophosphatemia,
and hypokalemia which were managed appropriately.