Iatrogenic Acute Hypermagnesemia After Total Parenteral Nutrition Infusion Mimicking Septic Shock Syndrome: Two Case Reports

Abstract

Two premature newborn infants developed extreme magnesium toxicity while receiving total parenteral nutrition (TPN) infusion. Both patients exhibited acute hypotonia, apnea, hypotension, and refractory bradycardia mimicking septic shock syndrome. The complete blood count was normal, and blood cultures were negative. Serum magnesium concentration in 1 patient was 43.1 mEq/L and in the other patient was 45 mEq/L (normal values for serum magnesium being 1.6-2.1 mEq/L). Hypermagnesemia resulted from malfunction of an automated TPN mixing device. Unexplained sudden onset of apnea, refractory bradycardia, and hypotension should raise suspicions of hypermagnesemia, a reversible condition if identified and treated early.

Severe hypermagnesemia presenting with abnormal electrocardiographic findings similar to those of hyperkalemia in a child undergoing peritoneal dialysis

“…Magnesium, the fourth most abundant cation and the second most common intracellular electrolyte, serves various important physiological functions6,8), including facilitating the activities of more than 300 enzyme systems and being essential for the production and proper function of DNA7). One of the primary functions of magnesium is to balance the activities of calcium in intracellular fluids that affect many organ systems such as the central nervous and cardiovascular systems, and neuromuscular junctions1).…”

“…The potential for misdiagnosis of hypermagnesemia in these patients may be high, not only because magnesium concentration is not measured routinely but because the initial symptoms of hypermagnesemia are nonspecific7). In addition, the electrocardiographic manifestations of hypermagnesemia are very similar to those of hyperkalemia, a more general complication observed in patients with renal insufficiency.…”

Early neonatal hypotension in premature infants born to preeclamptic mothers

“…The reported iatrogenically induced hypotension from hypermagnesemia occurred with a plasma magnesium level as high as 40 mEq/l. 21 We did not routinely check the serum magnesium level in our infants, but the dose of magnesium sulfate received by the mothers was within the recommended ranges and mothers were carefully monitored for magnesium toxicity. In our analysis, maternal preeclampsia but not maternal treatment with magnesium sulfate correlated with ENH.…”

“…These studies did not account for the possibility that the administration of intravenous magnesium sulfate to mothers with preeclampsia might have been the primary cause of neonatal hypotension. 21 We hypothesized that the putative effect of preeclampsia on neonatal arterial pressure is mediated by factor(s) related to maternal preeclampsia. This study was designed to clarify the relationship between maternal preeclampsia from any cause and early neonatal hypotension (ENH) after controlling for potential confounding variables.…”

Acute hypermagnesemia in a child

“…Ali et al 14 reported two cases of hypermagnesemia that resulted from a malfunction of an automatic total parenteral nutrition compounder, resulting in a solution with high concentrations of magnesium.…”