Diagnosis and Management of Hypermagnesemia

People at risk
1. CKD and HD patients who are receiving Mg containing drugs. 2. Anatcids and laxatives users. 3. gastrointestinal disorder (eg, gastritis, colitis, gastric dilation). 4. Lithium therapy. 5. Rhabdomyolysis. 6. Eclampsia. 7. Addisons disease. 8. Hypothyrodism. 9. Familial hypocalciuric hypercalcemia

When to suspect
Patients presenting with symptoms of hypermagnesmia (Neuromuscular symptom, heart block, hypotension, Paralytic ileus,Bleeding tendency,..)

Laboratory Assesment
Normal plasma Mg ranges from 1.7-2.3 mg/dL. Mild: Plasma Mg 2.4-4.8 mg/dL. Moderete: Plasma Mg concentration 4.8 to 12 mg/dL. Severe: Plasma Mg concentration above 12 mg/dL.

 Hyperkalemia and hypercalcemia are often present concurrently. Obtain renal function tests and calculate creatinine clearance to assess the ability of the kidney to excrete magnesium. Serum magnesium levels rise when creatinine clearance is less than 30 mL/min. Arterial blood gases (ABG) may reveal a respiratory acidosis.

 An ECG and cardiac monitor may show prolongation of the PR interval or intraventricular conduction delay, which are nonspecific findings. The ECG findings may reflect other electrolyte abnormalities such as hyperkalemia. Search for the cause: e.g. Thyroid function tests, CPK and urine myoglobin .

Emergency Department Care

Assess the patient's ABC and stabilize. Arrange ICU monitoring if the symptoms are severe Intubate if necessary. mechanical ventilation for respiratory failure and a temporary pacemaker for bradyarrhythmias.

Calcium gluconate
Calcium directly antagonizes neuromuscular and cardiovascular effects of magnesium. Use for patients with symptomatic hypermagnesemia that is causing cardiac effects or respiratory distress. Suggested dosing: 1020 ml IV (12 g) over 10 min;

Glucose and insulin

May help promote magnesium entry into cells. Glucose should be administered with insulin to prevent hypoglycemia.

Intravenous fluids
Intravenous fluids work by dilution of the extracellular magnesium. Fluids are used with diuretics to promote increased excretion of magnesium by the kidney. Normal saline or lactated Ringer solution 150 200 ml/hour till resoration of volume depletion Close monitoring of cardiovascular and pulmonary function; fluids should be stopped when desired hemodynamic response is seen or pulmonary edema develops.

Diuretics
These agents increase excretion of magnesium by the kidney. Furosemide (Lasix) Acts at loop of Henle to promote loss of magnesium in urine. 1-2 mg/kg/dose.

 dialysis with a low or zero magnesium dialysate should be instituted. Hemodialysis is extremely effective at removing excess Mg As a rough rule, the expected change in serum Mg2+ after a 3- to 4-hour dialysis session with a high-efficiency membrane is approximately 80% of total serum Mg2+. Peritoneal dialysis is also effective at Mg removal.

 For mild cases: Furosemide 20-80 mg/day