Iatrogenic magnesium toxicity following intravenous infusion of magnesium sulfate: risks and strategies for prevention

Hypermagnesemia- and Hyperphosphatemia-Associated Cardiac Arrest after Injection of a Novel Magnesium-Based Bone Cement in Spinal Surgery

We report a case of pulseless electrical activity (PEA) associated with profound hypermagnesemia immediately after cementation of a novel magnesium-based cement in spine surgery. During T8 to T12 posterior instrumentation and decompression laminectomy for vertebral metastasis secondary to lung cancer, a 61-year-old Chinese woman developed sudden hypotension and went into PEA immediately after injection of a novel magnesium-based cement. Intraoperative fluoroscopic imaging did not show any notable cement extravasation. Resuscitation using intravenous epinephrine with five doses of 1-mg epinephrine in 1:10,000 dilution was instituted, and the patient had return of spontaneous circulation after 5 minutes. After successful resuscitation, surgery was expedited and completed. Intraoperative and postoperative investigations were notable for profound hypermagnesemia and hyperphosphatemia requiring diuresis. No echocardiographic or computerized tomographic evidence of pulmonary embolism was found. The patient was transferred to the surgical intensive care unit and remained on dual inotropic support over the next few days. She subsequently weaned off inotropic support and electrolyte imbalances resolved before making a full recovery. This case report demonstrates the severe magnesium toxicity and PEA related to the use of novel magnesium-based cement in spine surgery. Further studies need to be conducted to understand the potential complications related to its use and compare them to the standard bone cement implantation syndrome.

Carbon Monoxide as a Potential Therapeutic Agent: A Molecular Analysis of Its Safety Profiles

Carbon monoxide (CO) is endogenously produced in mammals, with blood concentrations in the high micromolar range in the hemoglobin-bound form. Further, CO has shown therapeutic effects in various animal models. Despite its reputation as a poisonous gas at high concentrations, we show that CO should have a wide enough safety margin for therapeutic applications. The analysis considers a large number of factors including levels of endogenous CO, its safety margin in comparison to commonly encountered biomolecules or drugs, anticipated enhanced safety profiles when delivered via a noninhalation mode, and the large amount of safety data from human clinical trials. It should be emphasized that having a wide enough safety margin for therapeutic use does not mean that it is benign or safe to the general public, even at low doses. We defer the latter to public health experts. Importantly, this Perspective is written for drug discovery professionals and not the general public.

Role of Magnesium in the Intensive Care Unit and Immunomodulation: A Literature Review

Both the role and the importance of magnesium in clinical practice have grown considerably in recent years. Emerging evidence suggests an association between loss of magnesium homeostasis and increased mortality in the critical care setting. The underlying mechanism is still unclear, but an increasing number of in vivo and in vitro studies on magnesium's immunomodulating capabilities may shed some light on the matter. This review aims to discuss the evidence behind magnesium homeostasis in critically ill patients, and its link with intensive care unit mortality via a likely magnesium-induced dysregulation of the immune response. The underlying pathogenetic mechanisms, and their implications for clinical outcomes, are discussed. The available evidence strongly supports the crucial role of magnesium in immune system regulation and inflammatory response. The loss of magnesium homeostasis has been associated with an elevated risk of bacterial infections, exacerbated sepsis progression, and detrimental effects on the cardiac, respiratory, neurological, and renal systems, ultimately leading to increased mortality. However, magnesium supplementation has been shown to be beneficial in these conditions, highlighting the importance of maintaining adequate magnesium levels in the intensive care setting.

Hypomagnesemia in critically ill patients

BACKGROUND

Magnesium (Mg) is essential for life and plays a crucial role in several biochemical and physiological processes in the human body. Hypomagnesemia is common in all hospitalized patients, especially in critically ill patients with coexisting electrolyte abnormalities. Hypomagnesemia may cause severe and potential fatal complications if not timely diagnosed and properly treated, and associate with increased mortality.

MAIN BODY

Mg deficiency in critically ill patients is mainly caused by gastrointestinal and/or renal disorders and may lead to secondary hypokalemia and hypocalcemia, and severe neuromuscular and cardiovascular clinical manifestations. Because of the physical distribution of Mg, there are no readily or easy methods to assess Mg status. However, serum Mg and the Mg tolerance test are most widely used. There are limited studies to guide intermittent therapy of Mg deficiency in critically ill patients, but some empirical guidelines exist. Further clinical trials and critical evaluation of empiric Mg replacement strategies is needed.

CONCLUSION

Patients at risk of Mg deficiency, with typical biochemical findings or clinical symptoms of hypomagnesemia, should be considered for treatment even with serum Mg within the normal range.