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.