Safety of prolonged magnesium sulfate infusions during treatment for severe pediatric status asthmaticus

Abstract

Objective Magnesium sulfate (Mg) is one of several “second‐tier” therapies for treating severe status asthmaticus. Pediatric reports primarily describe bolus use with limited data regarding prolonged infusions. We sought to describe the safety of prolonged Mg infusions during therapy of status asthmaticus in critically ill children. Design Single center, retrospective study. Setting Thirty‐four‐bed tertiary level medical/surgical/cardiac surgical pediatric intensive care unit. Patients Pediatric patients 2 to 18 years of age admitted with status asthmaticus receiving Mg infusion for more than 24 hours. Interventions None. Measurements and main findings A total of 154 children received Mg infusions for a median of 53.4 hours (interquartile range = 36.6‐74.8). The most common adverse event (AE) was hypotension (48.1%), almost exclusively diastolic (94%), and was mostly limited to 1 blood pressure measurement (78%). 2.9% of events required intervention (fluids, decrease Mg infusion). Other AEs included nausea/emesis (22.7%), transient weakness (14.9%), and flushing (6.5%). Five patients experienced serious AEs including hypotonia (n = 1), escalation to continuous or bilevel positive airway pressure (n = 3), and sedation (n = 1), all attributed to progression of underlying medical disease. No patient required endotracheal intubation. Supratherapeutic levels (>6 mg/dL) were uncommon (2%) and were not more likely to be associated with AEs. Most (81%) patients were therapeutic by the 2nd Mg level check. Conclusion Prolonged Mg infusions were well tolerated in pediatric status asthmaticus patients. While diastolic hypotension was not uncommon, rarely were interventions deemed necessary. No serious AEs were attributed to Mg. Toxicity was uncommon suggesting that Mg levels could potentially be checked less frequently than historically reported.

Use of Magnesium Sulfate in Continuous Infusion in Patients With Severe Acute Asthma, in a Pediatric Emergency Room

“…The ideal level of serum magnesium for the treatment of wheezing exacerbations in childhood is not well established in the literature. Several studies have reported achieving therapeutic efficacy with serum concentrations between 3 and 5 mg/dL, corroborating the data found in this study in which the median serum magnesium was 4.3 (3.9-4.6) after 4 hours of infusion (13)(14)(15)(16)(17)(18)(19)(20).…”

“…Symptoms such as nausea, flushing, drowsiness, changes in vision and muscle weakness are more common when serum magnesium concentrations exceed 9 mg/dL. On the other hand, Graft and collaborators observed that the maintenance of serum magnesium levels between 4 and 6 mg/dL are effective in avoiding clinical signs of toxicity (15). From the data found in this study, we can observe that the use of magnesium sulfate by continuous infusion in 4 hours at a dose of 50mg/kg/hour raises the serum magnesium level to therapeutic values, non-toxic however (14,15,19).…”

“…As a strategy to maintain a consistent therapeutic serum level to compensate for rapid renal elimination, some researchers have proposed the continued use of magnesium sulfate intravenously (14)(15)(16)(17)(18)(19)(20). In a recent study carried out by Irazuzta and collaborators, they demonstrated that the use of magnesium sulfate, at a dose of 50mg/kg/hour for 4 hours when compared to bolus treatment (50mg/kg/hour in 1 hour), had better results in the time of disease progression, improvement in lung function, reduction in the hospitalization rate and a better cost-benefit ratio (17).…”

Lebensrettende Maßnahmen bei Kindern (Paediatric Life Support, PLS)

“…Ältere Publikationen wurden berücksichtigt, wenn die Erkenntnisse als informativ angesehen werden konnten [ 388 – 393 ]. Das Suchupdate von Juni 2020 enthüllte zusätzlich eine Leitlinie [ 394 ], 3 SR [ 395 – 397 ], eine narrative Übersicht [ 398 ], ein RCT [ 399 ] und 4 Beobachtungsstudien [ 400 – 403 ]. Es wurden die von der Globalen Initiative für Asthma (ginasthma.org) und den französischen pädiatrischen Notfallgesellschaften veröffentlichten Leitlinien als qualitativ hochwertig eingestuft (AGREE II) und deshalb die Empfehlungen weitgehend darauf basiert [ 394 ].…”

Life-threatening bronchial asthma in children: from predictors to prognosis

“…Таким образом, сульфат магния может быть использован при среднетяжелых или тяжелых обострениях астмы с 2 лет у пациентов с минимальным ответом на бронходилататоры и кортикостероиды [51].…”