Magnesium Sulfate Infusion Research Articles

Effect of postnatal magnesium therapy on neonatal seizure in infants with moderate to severe hypoxic ischemic encephalopathy: a post- hoc subgroup analysis

Background: Magnesium has got both neuroprotective and anticonvulsant effect on developing human brain. A post hoc subgroup analysis was done to determine the effect of magnesium on neonatal seizures in infants with moderate-severe hypoxic ischemic encephalopathy (HIE) who received postnatal magnesium therapy for perinatal asphyxia. Methods: Term asphyxiated infants were randomly assigned to receive either magnesium sulphate infusion or placebo within 48 hours of life to maintain serum magnesium levels in neuroprotective range. Short term neurological outcome at discharge was evaluated. The post hoc analysis evaluated the effect of magnesium on neonatal seizures in infants with moderate-severe HIE. All statistical analysis was done through SPSS (version 19.0) for windows and p value <0.05 was taken as statistically significant. Results: Sixty infants were included in magnesium and 60 in placebo group. Both groups were similar in baseline characteristics. Of 36 infants in magnesium group with moderate to severe HIE, 25 (69%) had neonatal seizures vs 27 (82%) of 33 infants in placebo group (p value 0.23). Among those with seizures, seizure control was achieved with single anticonvulsant in 24 infants (96%) in magnesium group vs 20 (74%) in placebo (p value 0.02). Seizures got controlled early in magnesium group compared to placebo, 36.5 hours vs 55 hours (p value 0.02). At discharge, anticonvulsant was required for 2 infants in magnesium group and 3 in placebo group. Conclusions: Postnatal magnesium therapy as a neuroprotective agent in moderate-severe HIE may decrease the duration of clinical seizures and need for multiple anticonvulsants during the critical period of neuronal damage.

Magnesium Sulfate as an Adjuvant to Anesthesia in Patients with Arterial Hypertension

There is limited evidence showing that elevated arterial blood pressure in surgical patients may be associated with increased perioperative risk; however, cardiovascular instability frequently occurs during anesthesia. The most commonly used anesthetic agents, both intravenous and inhalation ones, produce a decrease in arterial blood pressure. Magnesium, acting as a natural calcium-channel blocker, induces direct and indirect vasodilatation, thus playing a role in the treatment of arterial hypertension. In this research, we assessed the effects of magnesium sulfate on cardiovascular stability in patients undergoing diverse planned surgical procedures (abdominal, orthopedic, urology) under general balanced anesthesia, who were diagnosed with arterial hypertension grade 1 and 2. The research encompassed 100 patients of both sexes, aged from 20 to 65. Immediately before induction of anesthesia with propofol, the patients in the experimental group (50 study subjects) received 30 mg/ kg bolus dose and magnesium sulfate infusion at 10 mg/kg/h, whereas the subjects in the control group (50 patients) were administered normal saline. Anesthesia was achieved and maintained with sevoflurane, fentanyl and rocuronium. The hemodynamic variables of mean arterial pressure and heart rate were measured every five minutes, starting immediately before magnesium infusion. Statistical analysis of the categorized values of mean arterial pressure and heart rate revealed a statistically significant between-group difference at 60th and 90th minute of anesthesia. In conclusion, magnesium sulfate as an adjuvant to anesthesia in patients with arterial hypertension reduces hemodynamic changes during anesthesia.

Effect of intraoperative magnesium intravenous infusion on the hemodynamic changes associated with right lobe living donor hepatotomy under transesophageal Doppler monitoring-randomized controlled trial.

Background:Liver donors are subjected to specific postresection hemodynamic changes. The aim was to monitor these changes and to evaluate the effect of magnesium sulfate infusion (MgSO4) on these changes together with total anesthetic agents consumption.Patients and Methods:A total of 50 donors scheduled for right hepatotomy were divided into two equal groups. Controls (C) received saline and magnesium group (Mg) received MgSO4 10% (30 mg/kg over 20 min) administered immediately after induction of anesthesia, followed by infusion (10 mg/kg/h) till the end of surgery. Hemodynamics, transesophageal Doppler (TED) data and anesthetic depth guided by Entropy were recorded.Results:Postresection both groups demonstrated an increase in heart rate (HR) and cardiac output (COP) in association with lowering of systemic vascular resistance (SVR). The increase in HR with Mg was lower when compared with C, P = 0.00. Increase in COP was lower with Mg compared to (C) (6.1 ± 1.3 vs. 7.5 ± 1.6 L/min, P = 0.00) and with less reduction in SVR compared to C (1145 ± 251 vs. 849.2 ± 215 dynes.s/cm5, P < 0.01), respectively. Sevoflurane consumption was lower with Mg compared to C (157.1 ± 35.1 vs. 187.6 ± 25.6 ml, respectively, P = 0.001). Reduced fentanyl and rocuronium consumption in Mg group are compared to C (P = 0.00). Extubation time, postoperative patient-controlled fentanyl were lower in Mg than C (P = 0.001).Conclusion:TED was able to detect significant hemodynamic changes associated with major hepatotomy. Prophylactic magnesium helped to reduce these changes with lower anesthetic and analgesics consumption and an improvement in postoperative pain relief.

Revisiting Cerebral Palsy: Pathogenesis and Management

ABSTRACT Brain damage in utero and its consequences in neonates especially cerebral palsy (CP), are socially disturbing and psychologically distressing to both patients and carers. The prevalence of CP has not declined considerably despite several preventive measures in obstetric and neonatal care. Current views on the pathogenesis and causal pathways of CP relate to hypoxic-related ischemic events. A series of cascading events trigger the inflammatory processes resulting in gliosis of the white matter when labor and the delivery processes are reviewed. Though animal studies seem to support these concepts several other causes like perinatal infection and prematurity are also strong contributors to its pathogenesis. Multiple gestation and genetic factors may play a role in the etiology. Current management strategies focus on preventive measures during antenatal and intrapartum care. The use of antenatal steroids, magnesium sulfate infusion for cerebral protection and the extensive use of electronic fetal monitoring during labor have been elaborated as deliberate attempts to minimize the impact of any of the possible contributing cause. As CP is still prevalent in pediatric practice and in our community discussing means to improve prognosis of affected children are relevant. How to cite this article Aznal SS, Nalliah S, Chng TW. Revisiting Cerebral Palsy: Pathogenesis and Management. J South Asian Feder Obst Gynae 2016;8(1):57-65.

Preventive effect of continuous cisternal irrigation with magnesium sulfate solution on angiographic cerebral vasospasms associated with aneurysmal subarachnoid hemorrhages: a randomized controlled trial.

OBJECT Although cerebral vasospasm (CV) is one of the most important predictors for the outcome in patients with subarachnoid hemorrhage (SAH), no treatment has yet been established for this condition. This study investigated the efficacy of continuous direct infusion of magnesium sulfate (MgSO4) solution into the intrathecal cistern in patients with an aneurysmal SAH. METHODS An SAH caused by a ruptured aneurysm was identified on CT scans within 72 hours after SAH onset. All patients were treated by surgical clipping and randomized into 2 groups: a control group of patients undergoing a standard treatment and a magnesium (Mg) group of patients additionally undergoing continuous infusion of 5 mmol/L MgSO4 solution for 14 days. The Mg(2+) concentrations in serum and CSF were recorded daily. Neurological examinations were performed by intensive care clinicians. Delayed cerebral ischemia was monitored by CT or MRI. To assess the effect of the Mg treatment on CV, the CVs were graded on the basis of the relative degree of constriction visible on cerebral angiograms taken on Day 10 after the SAH, and transcranial Doppler ultrasonography was performed daily to measure blood flow velocity in the middle cerebral artery (MCA). Neurological outcomes and mortality rates were evaluated with the Glasgow Outcome Scale and modified Rankin Scale at 3 months after SAH onset. RESULTS Seventy-three patients admitted during the period of April 2008 to March 2013 were eligible and enrolled in this study. Three patients were excluded because of violation of protocol requirements. The 2 groups did not significantly differ in age, sex, World Federation of Neurosurgical Societies grade, or Fisher grade. In the Mg group, the Mg(2+) concentration in CSF gradually increased from Day 4 after initiation of the continuous MgSO4 intrathecal administration. No such increase was observed in the control group. No significant changes in the serum Mg(2+) levels were observed for 14 days, and no cardiovascular complications such as bradycardia or hypotension were observed in any of the patients. However, bradypnea was noted among patients in the Mg group. The Mg group had a significantly better CV grade than the control group (p < 0.05). Compared with the patients in the Mg group, those in the control group had a significantly elevated blood flow velocity in the MCA. Both groups were similar in the incidences of cerebral infarction, and the 2 groups also did not significantly differ in clinical outcomes. CONCLUSIONS Continuous cisternal irrigation with MgSO4 solution starting on Day 4 and continuing to Day 14 significantly inhibited CV in patients with aneurysmal SAH without severe cardiovascular complications. However, this improvement in CV neither reduced the incidence of delayed cerebral ischemia nor improved the functional outcomes in patients with SAH.

The effect of intravenous magnesium sulfate infusion on serum levels of sodium and potassium in patients with aneurysmal subarachnoid hemorrhage.

Abnormal serum sodium levels are frequently observed among patients with aneurysmal subarachnoid hemorrhage (SAH) and may worsen cerebral edema or mass effect. Low serum potassium levels (hypokalemia) are also common among patients with aneurysmal SAH and are associated with prolonged QT interval and ventricular arrhythmia. Recent meta-analysis suggests that MgSO4 infusion improves the clinical outcome in patients after aneurysmal SAH; however, MgSO4 infusion may theoretically exacerbate electrolyte disturbance. We retrospectively reviewed the prospectively collected demographic and laboratory data of 100 patients after aneurysmal subarachnoid SAH in a neurosurgical center in Hong Kong. 51 patients had daily magnesium sulfate infusion for 14 days (Group 1) and 49 patients were managed similarly, without magnesium sulfate infusion (Group 2). Days of hypernatremia (mean+/-SD) were 2.0+/-2.7 for group 1 and 2.0+/-2.5 for group 2, p = 0.999; days of hyponatremia (mean+/-SD) were 2.7+/-3.1 for group 1 and 2.0+/-2.9 for group 2, p = 0.230; days of hypokalemia (mean+/-SD) were 4.5+/-3.1 for group 1 and 4.5+/-3.2 for group 2, p = 0.819. Hyperkalemia was uncommon in both groups. There was also no statistically significant difference between the two groups when the data were re-analyzed as severe hyponatremia, severe hypokalemia and severe hyperkalemia. Magnesium sulfate infusion was safe and did not seem to exacerbate the duration of electrolyte disturbance associated with aneurysmal subarachnoid hemorrhage.

Association between Cerebral Palsy or Death and Umbilical Cord Blood Magnesium Concentration.

This study aims to evaluate whether magnesium sulfate (MgSO4) infusion at the time of delivery or magnesium cord blood concentration is associated with cerebral palsy (CP) or death diagnosed by the age of 2 years. Secondary analysis of data from a randomized trial of MgSO4 versus placebo for prevention of CP or death among offspring of women with anticipated preterm delivery. This study cohort included singleton, nonanomalous fetuses, whose mothers received MgSO4 as neuroprophylaxis. The primary outcomes were CP or death diagnosed by the age of 2 years. A total of 936 neonates (93 with CP or death, 843 controls) were included in the analysis. Infants in the group with CP or death had MgSO4 infusing at delivery at a similar frequency to that of controls (49 [52.7%] vs. 463 [54.9%], p = 0.68). Mean concentrations of cord blood magnesium, available for 596 neonates, also were not different between the two groups (2.7 ± 0.9 vs. 2.6 ± 0.9 mEq/L, p = 0.66, respectively). Multivariable analyses did not alter these findings. Among the offspring of women exposed to MgSO4, in utero, neither MgSO4 infusion at the time of delivery nor magnesium cord blood concentration is associated with CP or death.

Acute Renal Failure in Pregnancy

Poster Presentation Background Acute renal failure is a rare, life‐threatening complication of severe preeclampsia and hemolysis elevated liver enzymes and low platelets syndrome (HELLP). This condition occurs in an estimated 1 in 20000 pregnancies. Acute renal failure presents challenges for even the expert nurse. The purpose of this presentation is to assist obstetric nurses in recognizing complications of severe preeclampsia such as acute renal failure and empower them with the knowledge and skills to manage women with this condition to improve outcomes. Case A 25‐year‐old G1P0 woman at 39 weeks gestation arrived in our obstetric triage unit with complaints of a constant headache, visual disturbances, epigastric pain, and contractions for one hour. Initial blood pressure was 190/125 and fetal heart tones were not present on auscultation. After immediate notification to the obstetric (OB) triage attending physician, an intravenous line (IV) was started, lab work was drawn, IV antihypertensive medication was administered, and a magnesium sulfate infusion was started. After evaluation, the woman was diagnosed with an intrauterine fetal demise secondary to superimposed preeclampsia and HELLP syndrome. She was admitted to our labor and delivery unit for induction of labor. Within 24 hours of admission, maternal/fetal medicine, nephrology, neurology, and optometry were consulted. During induction, lab work was ordered every 4 hours and disseminated intravascular coagulation (DIC) was diagnosed, which required multiple blood transfusions. Urine output was minimal and renal lab values were elevated with an initial creatinine of 1.6 that peaked at 7.6. The woman required the placement of a tunnel catheter and dialysis short term while in the hospital. She continued to have complaints of visual disturbances and was diagnosed with retinal detachment related to DIC and preeclampsia. The woman was discharged one week postpartum on oral antihypertensive medication after her course of dialysis was completed. Conclusion Management of this woman with superimposed preeclampsia and HELLP syndrome with complications of DIC and acute renal failure presented a challenge to our health care team. Management required a multidisciplinary team approach to prevent further deterioration of kidney function and kidney disease. Acute renal failure was identified early by the health care team. The collaboration of the health care team and their ability to utilize each other's knowledge and expertise resulted in the woman being on dialysis short term, restoration of her kidney function, and her discharge on oral antihypertensive medication.

Abstract P3-12-10: Calcium and magnesium infusion for the prevention of taxane induced neuropathy in early stage breast cancer

Abstract Background: Taxane is an active drug in the treatment of breast cancer, but peripheral neuropathy is a major dose limiting side effect. There are currently no effective drugs or treatment modalities for the prevention or treatment of taxane-related neuropathy. We examined whether calcium and magnesium (Ca/Mg) infusions can reduce the incidence of neuropathy in patients with early stage breast cancer who are treated with paclitaxel. Methods: This was a pilot study evaluating the feasibility of Ca/Mg infusion to prevent taxane induced neuropathy in women with early stage breast cancer receiving adjuvant or neo-adjuvant paclitaxel treatment, either given every 2 weeks for 4 cycles or every week for 12 weeks. All patients received calcium gluconate and magnesium sulfate infusion, 1 g of each agent immediately before and after each dose of paclitaxel. The primary endpoint was paclitaxel-related neuropathy grade 2 or greater as measured by NCI Common Terminology Criteria Version 3 compared with historical controls. Secondary endpoints included other measures of neuropathy and quality of life such as the Functional Assessment of Cancer Therapy-Taxane (FACT-Tax) score, taxane-related neuropathic pain as measured by the Brief Pain Inventory-Short Form (BPI-SF). The endpoints were assessed in patients midway through treatment, at the end of treatment and 4 weeks after finishing taxane therapy. Results: We enrolled 50 patients, 47 patients were evaluable, and 3 patients were taken out of the study due to non-neuropathy related side effects or progression of disease. Median age: 50.8 (range 27-71), White/Hispanic/Black/Asian/Other: 17/16/12/3/2. Two patients received paclitaxel every 2 weeks, while the remainder received weekly therapy. Eight of 47 patients (17%) had grade 2 neuropathy four weeks after treatment completed, while no patients had grade 3 or 4 neuropathy. This rate of neuropathy is significantly lower compared to that seen in historical control where approximately 30% of patients develop grade 2 or greater neuropathy. There were no significant changes in the quality of life measurements. There were no observed toxicities related to the Ca/Mg infusion. Discussion: Our study showed a decreased incidence of paclitaxel-related neuropathy in patients receiving Ca/Mg infusions when compared to historical controls. The infusions are well tolerated without any side effects. Randomized studies are warranted to further evaluate Ca/Mg infusion for the prevention of paclitaxel-related neuropathy. Citation Format: Theresa Shao, Joshua Kra, Paula Klein, Anupama Goel, Stephen Malamud, Tiffany Xing, Johnny Chan, Michael L Grossbard. Calcium and magnesium infusion for the prevention of taxane induced neuropathy in early stage breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-12-10.

Use of Magnesium Sulfate Infusion for the Management of Febrile Illness-Related Epilepsy Syndrome: A Case Series.

Febrile illness-related epilepsy syndrome is a catastrophic epileptic encephalopathy that is highly refractory to most antiepileptic drugs leading to high morbidity and mortality. The authors report the use of a pediatric infusion protocol of continuous intravenous magnesium sulfate for the control of seizures in 2 children with febrile illness-related epilepsy syndrome refractory to multiple antiepileptic drugs in a pediatric intensive care unit of a tertiary care children’s hospital. Both patients, 2 and 16 years of age, respectively, were treated with continuous magnesium sulfate infusion. Serum magnesium concentrations ranging from 2.1 to 5 mmol/L were achieved. Seizure reduction and cessation were noted in 1 patient with magnesium more than 3.0 mmol/L. No significant adverse effects were observed. Magnesium sulfate infusions can be safely used in pediatric refractory status epilepticus. Magnesium sulfate can be considered in the management of children with febrile illness-related epilepsy syndrome.

Comparative study between succinylcholine, rocuronium and magnesium sulphate with rocuronium in rapid sequence induction

Background Rapid sequence induction usually applies when tracheal intubation must be performed in a patient who is suspected of having a full stomach and who is at risk of pulmonary aspiration of gastric contents. Succinylcholine is the traditional depolarizing neuromuscular-blocking agent used in rapid sequence induction. However, it has a number of undesirable side effects. Magnesium may have a role in potentiation of neuromuscular blockade produced by neuromuscular blockers such as rocuronium. Aim The aim of this study was to investigate the effects of magnesium sulphate pretreatment on intubating conditions and cardiovascular responses during rapid sequence tracheal intubation (RSI). Patients and methods A total of 60 adult patients were randomly allocated to three groups: the succinylcholine group, which received 1 mg/kg succinylcholine; the rocuronium group, which received 1.2 mg/kg rocuronium preceded 15 min with 500 ml normal saline; and the magnesium rocuronium group, which received 1.2 mg/kg rocuronium preceded 15 min with 60 mg/kg magnesium sulphate in 500 ml normal saline infusion. Anaesthesia was induced with fentanyl, propofol and a neuromuscular-blocking drug on the basis of the studied group. An anaesthesiologist, blinded to the rocuronium group assignments, performed RSI and assessed the onset time, intubating conditions and clinical duration of neuromuscular block in the different groups. Haemodynamics were recorded before magnesium sulphate or normal saline infusion, after anaesthesia induction and every minute after intubation for 5 min. Results The onset time was shortest in the succinylcholine and magnesium groups. The intubating conditions were significantly better in the magnesium group (P Conclusion Magnesium sulphate administered before RSI using fentanyl, propofol and rocuronium may shorten the onset time and improve the intubating conditions comparable to those of succinylcholine and suppress the haemodynamic stress response to intubation.

Dexmedetomidine for anaesthetic management of phaeochromocytoma in a child with von Hippel-Lindau type 2 syndrome.

Phaeochromocytoma is a rare neoplasm in the paediatric population with fewer than 20% of diagnosed cases.[1] We describe the use of dexmedetomidine infusion for successful management of an 11-year-old male child with von Hippel-Lindau type 2 syndrome (VHL), who underwent bilateral adrenalectomy for phaeochromocytoma.

Dexmedetomidine versus magnesium sulfate for oligemic field in middle ear surgery

Aim of study To compare between the effects of dexmedetomidine and magnesium sulphate on quality of surgical field visualization in middle ear surgery. Patients and Methods 60 patients scheduled for middle ear surgery were included in the study. Patients were randomly divided into two equal groups, the 1st group received dexmedetomidine infusion (D group) while the 2nd received magnesium sulphate infusion (Mg group). Induction of anesthesia was done by propofol 2 mg/kg and atracurium 0.5 mg/kg. Anesthesia was maintained with sevoflurane which titrated to obtain 30% decrease in blood pressure. Infusion of dexmedetomidine 1 μg/kg over 10 minutes followed by 0.5 μg/kg/hr in D group while infusion of 50 mg/kg magnesium sulphate over 10 minutes followed by 15 mg/kg/hr magnesium sulphate in Mg group. Quality of surgical field visualization, Amount of blood loss, blood pressure, heart rate and postoperative side effects were recorded. Results Quality of surgical field visualization was better and amount of blood loss was less in group D than group Mg without serious side effect. Conclusion Dexmedetomidine provided better quality of surgical field vision and less bleeding when compared to magnesium sulphate without any side effects in middle ear surgery.

Evaluation of the anti-inflammatory effects of peri-operative infusion of magnesium sulfate on the microsurgical procedures for intracranial tumors.

Background:The anti-inflammatory properties of magnesium sulfate have never been discussed in brain tumor surgeries.Objectives:This study is aimed to find anti-inflammatory aspects of high dose magnesium sulfate infusion during perioperative period of neurosurgical patients through checking the serial C-reactive protein (CRP) blood levels as a biomarker of inflammation.Patients and Methods:Sixty patients who were candidate for elective craniotomy were enrolled randomly into two equal groups to receive either magnesium sulfate or normal saline during their perioperative period. Infusion of magnesium was performed three times during the study and a summation of 15 grams was administered: 1- two days before surgery, 2- one day before surgery, 3- from the beginning of surgery (five grams was infused within six hours in each session). Serum level of CRP was checked just before commencement of magnesium infusion and on the first and second day after surgery as primary outcome. Hemodynamic parameters, total propofol requirement and total blood loss were recorded as well.Results:No significant difference was found between groups in terms of serum CRP levels. The mean arterial blood pressure, heart rate, blood loss and total anesthetic requirement were significantly lower in magnesium group in comparison to the control group.Conclusions:We did not find conclusive evidence for anti-inflammatory effects of magnesium in craniotomy for microsurgery of intracranial tumors using CRP level changes. However, high dose magnesium might be suggested as a safe anesthetic adjuvant in neurosurgery.

Effects of intravenous infusion of hydrogen-rich fluid combined with intra-cisternal infusion of magnesium sulfate in severe aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial.

BackgroundThe failures of recent studies intended to prevent cerebral vasospasm have moved the focus of research into delayed cerebral ischemia away from cerebral artery constriction towards other mechanisms. Recent accumulating evidence has suggested that early brain injury is also involved in the development of delayed cerebral ischemia, and that hydrogen can prevent early brain injury. Therefore, we have established a combination therapy of intravenous hydrogen infusion and intra-cisternal magnesium sulfate infusion for the treatment of both early brain injury and cerebral vasospasm. The present randomized controlled clinical trial is designed to investigate the effects of this novel therapeutic strategy on the occurrence of cerebral vasospasm, delayed cerebral ischemia, and clinical outcomes after high-grade subarachnoid hemorrhage.MethodsThis study is a randomized, double-blind, placebo-controlled design to be conducted in two hospitals. A total of 450 patients with high-grade subarachnoid hemorrhage will be randomized to one of three arms: (i) Mg + H2 group, (ii) Mg group, and (iii) control group. Patients who are assigned to the Mg + H2 group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous hydrogen-rich fluid infusion (200 mL) twice a day for 14 days. Patients who are assigned to the Mg group will receive intra-cisternal magnesium sulfate infusion (2.5 mmol/L) at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Patients who are assigned to the control group will receive intra-cisternal Ringer solution without magnesium sulfate at 20 mL/h for 14 days and intravenous normal glucose-electrolyte solution (200 mL) without added hydrogen twice a day for 14 days. Primary outcome measures will be occurrence of delayed cerebral ischemia and cerebral vasospasm. Secondary outcome measures will be modified Rankin scale score at 3, 6, and 12 months and biochemical markers.DiscussionThe present protocol for a randomized, placebo-controlled study of intravenous hydrogen therapy with intra-cisternal magnesium infusion is expected to establish the efficacy and safety of this therapeutic strategy.Trial registrationUMIN-CTR: UMIN000014696

Effect of preoperative Mg sulfate infusion on serum cardiac troponin (cTn) in moderate preeclamptic undergoing elective cesarean section under spinal anesthesia

This study was designed to investigate and compare the effect of preoperative Mg sulfate infusion on serum cardiac troponin (cTn) in moderate preeclampsia undergoing elective cesarean section. A total of fifty parturients having moderate preeclampsia scheduled for elective cesarean section were included. They were randomly allocated into two equal groups 25 each, magnesium group (GMg) received preoperative magnesium sulfate infusion and control group (GC) then both received spinal anesthesia, serum troponin measured preoperative then at 6, 12 and 24 h postoperative. Mean arterial pressure and heart rate were also recorded. Baseline serum cardiac troponin was higher above normal and was comparable at the rest of times in both groups. Mean arterial pressure readings were significantly lower in GMg compared to GC at induction of spinal, skin incision and skin closure (P < 0.05) and were comparable at the rest of times. Serum cardiac troponin (cTn) levels were comparable in parturients received magnesium sulfate infusion preoperatively with those did not receive magnesium sulfate.

Acute Renal Failure in Tetanus: Correspondence

To the Editor: We read the article ‘Acute renal failure in tetanus’ by Kaur et al. with interest [1]. The authors had reported acute kidney injury and myoglobinuria in a 10-y-old child with tetanus. We intend to highlight certain issues regarding the management of this child. The child was administered very high doses of intravenous diazepam (50 mg/kg/d) which could have predisposed to potentially life-threatening propylene glycol toxicity [2]. Propylene glycol (1, 2-propanediol) is a solvent used in intravenous preparation of lorazepam and diazepam. The toxic effects range from hyperosmolality, hemolysis, rhabdomyolysis, cardiac arrhythmia, seizure, and coma [3]. In addition, development of lactic acidosis, hypotension, and multisystem organ dysfunction in propylene glycol toxicity often mimic the features of septic shock. The normal range of serum creatinine in the 7–10 y age group is 0.22–0.6 mg/dL. The documented baseline serum creatinine level in this child was 0.9 mg/dL. This point to preexisting renal dysfunction at the onset; however, whether the underlying cause was ongoing rhabdomyolysis or autonomic dysfunction is a matter of debate. The child suffered sudden cardiac arrest on sixth day of hospitalization. The commonest cause of death in patients with severe tetanus on ventilator support is tetanusassociated autonomic dysfunction. Magnesium sulphate is useful for control of autonomic dysfunction in these patients. The muscle relaxation property of Magnesium sulphate controls spasms and cardiovascular manifestations (vasodilatation, lowering of heart rate, and reduction of systemic catecholamine release) and is responsible for ameliorating the ill effects of autonomic dysfunction. A recent randomized controlled trial also reiterated that magnesium sulphate infusion effected a reduction in the requirement of other drugs to control muscle spasms and cardiovascular instability without reducing the need for mechanical ventilation in patients with severe tetanus [4]. While managing acute kidney injury due to rhabdomyolysis, infusion of large volume of intravenous fluids within the first 24 h is associated with improved outcomes [5]. Alkalinization of the urine is also practiced routinely, but evidence of significant clinical benefit is lacking. A current consensus statement suggests that sodium bicarbonate administration is neither necessary nor superior to normal saline diuresis in increasing urine pH [5].

Dexmedetomidine in the management of severe tetanus

Sir, Although tetanus is a rare disease in the developed countries now, it remains a significant cause of death world-wide and is associated with a high rate of mortality. Components of severe tetanus management are supportive care with sedation, airway protection and controlled ventilation.[1] Dexmedetomidine is a high selective α-2-receptor agonist. It has combined analgesic and anti-sympathetic effect without respiratory system depression. There have been several studies describing its successful use in mechanically ventilated patients for short- (24 h) and long-term (up to 7 days) use in the intensive care unit (ICU).[2] Dexmedetomidine has been also used in the treatment of tetanus in six patients for 7 days.[3] We present a case of generalised tetanus complicated by uncontrolled sympathetic over activity (SOA) managed with dexmedetomidine infusion. A 53-year-old male patient presented with complaints of dyspnoea, upper lip twitching, difficulty in swallowing and a local abscess around his right foot. He had a medical history of penetrating wound in his right foot 11 days before. Antibiotics and human tetanus immunoglobulin were administered and the wound was surgically debrided. Because of respiratory failure with SOA, he was intubated and mechanically ventilated. SOA persisted despite midazolam and magnesium sulphate infusion. Dexmedetomidine infusion was started on day 5 and SOA could be controlled successfully. On day 10, severe bronchopneumonia developed and the patient died on day 12. The management of tetanus requires the prevention of tetanospasmin absorption, treatment of symptoms, stabilisation of autonomic instability, antibiotic therapy and control of the airway with assisted ventilation if indicated. Basal SOA is characterised by resting tachycardia and depression of bowel motility and bladder function, while severe SOA presents with fluctuating tachycardia, labile hypertension and sweating with and without stimulation.[4] Different methods to control SOA have been provided, including magnesium sulphate infusions, dantrolene infusions, intrathecal administration of baclofen, benzodiazepine, clonidine and dexmedetomidine.[5] Girgin et al.[3] reported use of dexmedetomidine in the management of tetanus for 7 days in six patients without any side-effects. According to the same author, its administration did not fully control the muscle spasm, but decreased their frequency and severity and reduced the use of sedative drugs to control muscle spasms and cardiovascular instability. In this case, we started dexmedetomidine infusion on the 5th day in the ICU, because midazolam and magnesium sulphate infusions did not efficiently control SOA. We observed that tachycardia (heart rate >110 beats/min) and hypertension (mean arterial blood pressure gt;100 mmHg) decreased to acceptable normal levels and need for sedative drugs was reduced after starting dexmedetomidine infusion. However, we were not able to fully avoid their use. We used dexmedetomidine for 4 days. Although hypotension and bradycardia are the most significant side-effects, we did not observe any of these and could control SOA during the first 3 days of the infusion. However, hypotension and bradycardia were observed on the 4th day of the infusion and hence we cut it off. The patient died because of nosocomial pneumonia despite multidrug antibiotherapy. Thus, dexemedetomidine can be a good alternative drug for resistant SOA during tetanus management.

Effect of pre-emptive magnesium sulfate infusion on the post-operative pain relief after elective cesarean section.

Background:The aim of this study was to evaluate the analgesic efficacy of pre-operative single dose of intravenous (I.V.) magnesium sulfate infusion in patients undergoing elective Cesarean section.Materials and Methods:Seventy pregnant women who underwent elective Cesarean section were randomly divided into two groups. Before induction of anesthesia, the magnesium group (Group A) received magnesium sulfate 50 mg/kg I.V. in bolus dose. The control group (Group B) received the same volume of isotonic saline. The pain scores at rest and also upon movement were evaluated up to 24 h post-operatively and analgesic requirement was recorded during the first 24 h after operation.Results:Cumulative analgesic consumption (24 h after operation was 11.2 ± 6.3 mg in group A vs. 13.9 ± 3.9 mg in group B). Post-operative pain scores (24 h after operation was 1.8 ± 2.1 in group A vs. 2.9 ± 1.2 in group B) and shivering incidents (8.57 in group A vs. 14.28 in group B) were significantly lower in Group A (P < 0.05). Mean arterial pressure just after intubation and during the immediate post-operative period was significantly lower in Group A (P < 0.05).Conclusion:Pre-operative intravenous magnesium sulfate infusion decrease post-operation pain and requirement of analgesia in Cesarean section.

The effect of intravenous magnesium sulfate infusion on sensory spinal block and postoperative pain score in abdominal hysterectomy.

Aim. The aim of this study was to investigate the effect of i.v. infusion of magnesium sulphate during spinal anesthesia on duration of spinal block and postoperative pain. Methods. Forty ASA physical status I and status II, aged between 18 and 65, female patients undergoing abdominal hysterectomy under spinal anesthesia were enrolled in this study. Patients in the magnesium group (Group M, n = 20) received magnesium sulphate 65 mg kg−1 infusion in 250 mL 5% dextrose at 3.5 mL/min rate, and control group (Group C, n = 20) received at the same volume of saline during operation in a double-blind randomized manner. Duration of sensory and motor block, systolic, diastolic, and mean arterial blood pressures, heart rates, pain scores (VAS values), and side effects were recorded for each patient. Blood and CSF samples were taken for analysis of magnesium concentrations. Results. Regression of sensorial block was longer in Group M when compared with that in Group C (175 ± 39 versus 136 ± 32 min) (P < 0.01). The VAS scores were lower in Group M than those in Group C at the 2 time points postoperatively (P < 0.01). Conclusion. 65 mg kg−1 of magnesium sulphate i.v. infusion under spinal anesthesia prolongs spinal sensorial block duration and decreases pain VAS scores without complication in patients undergoing abdominal hysterectomy.