Clinical correlates of the molecular and cellular actions of magnesium on the cardiovascular system

Analgesic Effects of Magnesium Sulphate as an Adjuvant to Fentanyl for Monitored Anaesthesia Care During Hysteroscopy

BACKGROUND

Magnesium sulphate (MgSO4) is conventionally used in the treatment of eclampsia, refractive arrhythmias, asthma, etc. In our study, we aimed to study the analgesic effects of MgSO4 as an adjuvant to fentanyl and reduce the intraoperative opioid requirement to decrease their adverse effects.

METHODS

A total of 122 patients scheduled for hysteroscopy were randomly divided into two groups. Patients in the magnesium group (group A) received intravenous MgSO4 50 mg/kg in 100 ml of isotonic saline over 15 minutes before anaesthesia induction and then 15 mg/kg per hour by continuous intravenous infusion. Patients in the control group (group B) received an equal volume of isotonic saline as a placebo. All the patients were induced with fentanyl and propofol. Perioperative haemodynamic monitoring and postoperative assessment of pain were done.

RESULTS

Only 18% of the patients in group A required rescue analgesics as compared to 39.3% of patients in group B. The patients receiving MgSO4 displayed lower verbal numeric rating scale scores in the postoperative period. In addition, the intraoperative requirement of fentanyl (101 (21.33) vs. 144 (28.4) µg, mean (SD)) and propofol (121 (13.3) vs. 140 (16.5) mg, mean (SD)) was significantly lower in group A as compared to that in group B.

CONCLUSION

MgSO4, when administered as an adjuvant to opioids, provided effective postoperative analgesia thereby reducing the need for rescue analgesics. It also decreases intraoperative fentanyl consumption and its dose-related side effects.

Advances in Modification Methods Based on Biodegradable Membranes in Guided Bone/Tissue Regeneration: A Review

Guided tissue/bone regeneration (GTR/GBR) is commonly applied in dentistry to aid in the regeneration of bone/tissue at a defective location, where the assistive material eventually degrades to be substituted with newly produced tissue. Membranes separate the rapidly propagating soft tissue from the slow-growing bone tissue for optimal tissue regeneration results. A broad membrane exposure area, biocompatibility, hardness, ductility, cell occlusion, membrane void ratio, tissue integration, and clinical manageability are essential functional properties of a GTR/GBR membrane, although no single modern membrane conforms to all of the necessary characteristics. This review considers ongoing bone/tissue regeneration engineering research and the GTR/GBR materials described in this review fulfill all of the basic ISO requirements for human use, as determined through risk analysis and rigorous testing. Novel modified materials are in the early stages of development and could be classified as synthetic polymer membranes, biological extraction synthetic polymer membranes, or metal membranes. Cell attachment, proliferation, and subsequent tissue development are influenced by the physical features of GTR/GBR membrane materials, including pore size, porosity, and mechanical strength. According to the latest advances, key attributes of nanofillers introduced into a polymer matrix include suitable surface area, better mechanical capacity, and stability, which enhances cell adhesion, proliferation, and differentiation. Therefore, it is essential to construct a bionic membrane that satisfies the requirements for the mechanical barrier, the degradation rate, osteogenesis, and clinical operability.

Circulating Serum Magnesium and the Risk of Venous Thromboembolism in Men: A Long-Term Prospective Cohort Study

Background and Objective

Serum magnesium, an essential trace element involved in processes that regulate cardiovascular function, has been linked to the risk of atherosclerotic cardiovascular disease. However, the potential association between serum magnesium and venous thromboembolism (VTE) has not been previously investigated. We aimed to assess the prospective association of serum magnesium with the risk of VTE.

Methods

Serum magnesium was measured using atomic absorption spectrometry in 2,361 men aged 42-61 years with no history of VTE at baseline in the Kuopio Ischemic Heart Disease prospective cohort. Cox regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for VTE.

Results

A total of 159 incident VTE events were recorded during a median follow-up of 27.1 years. The risk of VTE per 1 SD increase in serum magnesium in the age-adjusted analysis was (HR 1.30; 95% CI 0.46-3.69). The association remained consistent in analyses adjusted for systolic blood pressure, body mass index, total cholesterol, triglycerides, smoking status, a history of type 2 diabetes, a history of coronary heart disease, medication for dyslipidemia, alcohol consumption, physical activity, socioeconomic status, serum active calcium, high-sensitivity C-reactive protein, and a history of cancer (HR 1.38; 95% CI 0.48-3.96). Comparing the extreme tertiles of serum magnesium, the corresponding adjusted HRs were 1.17 (95% CI 0.81-1.70) and 1.17 (95% CI 0.81-1.70), respectively.

Conclusion

In a middle-aged Caucasian male population, serum-circulating magnesium was not associated with a future risk of VTE. Further studies in women, other age groups, and other populations are required to generalize these findings.

The effects of electroporation buffer composition on cell viability and electro-transfection efficiency

Electroporation is an electro-physical, non-viral approach to perform DNA, RNA, and protein transfections of cells. Upon application of an electric field, the cell membrane is compromised, allowing the delivery of exogenous materials into cells. Cell viability and electro-transfection efficiency (eTE) are dependent on various experimental factors, including pulse waveform, vector concentration, cell type/density, and electroporation buffer properties. In this work, the effects of buffer composition on cell viability and eTE were systematically explored for plasmid DNA encoding green fluorescent protein following electroporation of 3T3 fibroblasts. A HEPES-based buffer was used in conjunction with various salts and sugars to modulate conductivity and osmolality, respectively. Pulse applications were chosen to maintain constant applied electrical energy (J) or total charge flux (C/m2). The energy of the pulse application primarily dictated cell viability, with Mg2+-based buffers expanding the reversible electroporation range. The enhancement of viability with Mg2+-based buffers led to the hypothesis that this enhancement is due to ATPase activation via re-establishing ionic homeostasis. We show preliminary evidence for this mechanism by demonstrating that the enhanced viability is eliminated by introducing lidocaine, an ATPase inhibitor. However, Mg2+ also hinders eTE compared to K+-based buffers. Collectively, the results demonstrate that the rational selection of pulsing conditions and buffer compositions are critical for the design of electroporation protocols to maximize viability and eTE.

Magnesium: Pathophysiological mechanisms and potential therapeutic roles in intracerebral hemorrhage

Intracerebral hemorrhage (ICH) remains the second-most common form of stroke with high morbidity and mortality. ICH can be divided into two pathophysiological stages: an acute primary phase, including hematoma volume expansion, and a subacute secondary phase consisting of blood-brain barrier disruption and perihematomal edema expansion. To date, all major trials for ICH have targeted the primary phase with therapies designed to reduce hematoma expansion through blood pressure control, surgical evacuation, and hemostasis. However, none of these trials has resulted in improved clinical outcomes. Magnesium is a ubiquitous element that also plays roles in vasodilation, hemostasis, and blood-brain barrier preservation. Animal models have highlighted potential therapeutic roles for magnesium in neurological diseases specifically targeting these pathophysiological mechanisms. Retrospective studies have also demonstrated inverse associations between admission magnesium levels and hematoma volume, hematoma expansion, and clinical outcome in patients with ICH. These associations, coupled with the multifactorial role of magnesium that targets both primary and secondary phases of ICH, suggest that magnesium may be a viable target of study in future ICH studies.

Magnesium attenuates cisplatin-induced nephrotoxicity by regulating the expression of renal transporters

Cisplatin (CDDP)-induced nephrotoxicity (CIN) is one of the most serious toxicities caused by this potent antitumor agent. It has been reported that Mg premedication attenuates CIN in clinical trials; however, the mechanism underlying its nephroprotection is not fully understood. Therefore, the aim of this study was to determine whether Mg administration affects CDDP accumulation by regulating the expression level of renal transporters. Rats were divided into control, Mg (40mg/kg) alone, 2.5mg/kg CDDP with (20 and 40mg/kg) and without Mg, 5mg/kg CDDP groups. These substances were administered on the same day and 7 days later their kidneys were removed. The expression levels of renal transporters and platinum (Pt) accumulation were analyzed. The serum creatinine level was significantly increased by CDDP administration and treatment with Mg significantly ameliorated such elevation. The expressions of the renal organic cation transporter 2 (rOct2) and renal multidrug and toxin extrusion protein 1 (rMate1) were downregulated and upregulated, respectively following co-administration with Mg, which significantly reduced the renal Pt accumulation in the 2.5mg/kg CDDP-treated group. Moreover, Mg dose-dependently downregulated rOct2, not affecting rMate expression, resulting in the attenuation of CIN. Mg co-administration protected the downregulation of the transient receptor potential subfamily Melastatin 6 (rTrpm6), but not the epidermal growth factor (rEgf), as a result, Mg co-injection attenuated CDDP-induced hypomagnesemia. In conclusion, Mg co-administration reduced Pt accumulation by regulating the expression of the renal transporters, rOct2 and rMate1 and, thereby, attenuated CIN.

Comparative evaluation between two methods of induced hypotension with infusion of Remifentanil and Labetalol during sinus endoscopy

OBJECTIVE

This study aimed to compare two methods of controlled hypotension using labetalol and remifentanil in terms of capability to create controlled hypotension and to investigate the obtained complications, and satisfaction rate of surgeon and patient during functional endoscopic sinus surgery.

METHODS

In this prospective clinical trial, 62 patients underwent endoscopic sinus surgery in Al-Zahra and Ayatollah Kashani Hospitals of Isfahan were divided into two groups: in the first group, 20 mg bolus dose of labetalol and then infusion of it, at a rate of 0.5-2.0 mg/min and in the second group, remifentanil with dose of 0.5-1 μg/kg started and then 0.25-0.5 μg/kg/min were prescribed. Hemodynamic parameters during anesthesia and recovery time, surgeon and patient satisfaction, and recovery time were measured and recorded.

FINDINGS

Hemodynamics variable were comparable between two groups at different times of the study. The mean of bleeding and the frequency of side effects were higher in labetalol group (P = 0.033 and P < 0.0001, respectively). The median of surgeon satisfaction score in remifentanil group was statistically higher in labetalol group (P < 0.0001). Recovery time, fluid requirement, and pain score in labetalol group reported significantly more than remifentanil group. Richmond Agitation-Sedation Scale status at time points in the postanesthetic care unit showed differences between groups.

CONCLUSION

With infusion of labetalol and remifentanil after a bolus dose we can induce effective controlled hypotension under general anesthesia. Remifentanil is a short-acting narcotic drug; then, patient satisfaction was better and recovery time was shorter. From the economic aspect, labetalol prefers to remifentanil.

Review of epidemiological studies on drinking water hardness and cardiovascular diseases

BACKGROUND

Major risk factors do not entirely explain the worldwide variability of morbidity and mortality due to cardiovascular disease. Environmental exposures, including drinking water minerals may affect cardiovascular disease risks.

METHOD

We conducted a qualitative review of the epidemiological studies of cardiovascular disease and drinking water hardness and calcium and magnesium levels.

RESULTS

Many but not all ecological studies found an inverse (i.e., protective) association between cardiovascular disease mortality and water hardness, calcium, or magnesium levels; but results are not consistent. Some case-control studies and one cohort study found either a reduced cardiovascular disease mortality risk with increased drinking water magnesium levels or an increased risk with low magnesium levels. However, the analytical studies provide little evidence that cardiovascular risks are associated with drinking water hardness or calcium levels.

CONCLUSION

Information from epidemiological and other studies supports the hypothesis that a low intake of magnesium may increase the risk of dying from, and possibly developing, cardiovascular disease or stroke. Thus, not removing magnesium from drinking water, or in certain situations increasing the magnesium intake from water, may be beneficial, especially for populations with an insufficient dietary intake of the mineral.

Magnesium: potential roles in neurovascular disease

OBJECTIVE

Magnesium therapy has been studied extensively in pre-clinical and clinical trials in multiple organ systems. Cerebrovascular diseases may benefit from its neuroprotective properties. This review summarizes current studies of magnesium in a wide range of neurovascular diseases.

METHODS

We searched relevant terms in the National Library of Medicine PubMed database and selected research including basic science, translational reports, meta-analyses, and clinical studies.

RESULTS

Studies examining magnesium administration in ischemic stroke have failed to show any benefit in clinical outcome. Data on magnesium for intracerebral hemorrhage (ICH) are limited. Preliminary investigations in subarachnoid hemorrhage (SAH) were promising, but definitive studies did not reveal differences in clinical outcome between magnesium and placebo-treated groups. Studies examining magnesium administration in global ischemia following cardiac arrest suggest a trend toward improved clinical outcome. The strongest evidence for clinically relevant neuroprotection following magnesium administration derives from studies of pre-term infants and patients undergoing cardiac bypass and carotid endarterectomy procedures. Magnesium was found to have an excellent safety profile across all investigations.

CONCLUSION

Magnesium is easy to administer and possesses a favorable safety profile. Its utility as a neuroprotectant in cardiac surgery, carotid endarterectomy, and pre-term infant hypoxia remain promising. Value as a therapeutic agent in ischemic stroke, ICH, and SAH is unclear and appears to be limited by late administration. Ongoing clinical trials assessing magnesium administration in the first hours following symptom onset may help clarify the role of magnesium therapy in these disease processes.

Effect of continuous magnesium sulfate infusion on spinal block characteristics: A prospective study

Background:

Spinal anesthesia is an established mode of anesthesia for lower limb orthopedic surgeries. The limitations of the technique are short duration of action and limited post-operative analgesia. Concomitant use of intravenous infusion of magnesium sulfate may have an effect on the block characteristics and duration of action of intrathecal bupivacaine.

Methods:

A total of 80 American Society of Anesthesiologists I and II patients, either sex, 20-60 years of age scheduled for elective orthopedic fixation of fracture of long bones of lower limbs under spinal anesthesia were included. Spinal anesthesia administered with 2.5 ml heavy bupivacaine mixed with 10 mcg fentanyl. The groups were then divided to receive an infusion of injection magnesium sulfate 50 mg/kg/h over 15 min followed by 15 mg/kg/h until the end of the surgery (Group M) and 15 ml of Normal Saline over 15 min followed by 100 ml/h until the end of surgery (Group S). Onset, duration of sensory and motor block and amount of post-operative analgesic were noted.

Results:

A total of 6 patients (Group M) and seven patients (Group S) had inadequate block and excluded from the study. Mean block height was T6. Time required to achieve block height was 8.82 min versus 7.42 min in Groups M and S respectively (P = 0.04). Mean duration of motor block was longer in group M (160.63 ± 17.76 min) compared with Group S (130.12 ± 20.70 min) (P = 0.000). Time for regression of sensory block to T12/L1was 206.88 ± 20.96 min (Group M) and 163.88 ± 15.46 min (Group S) (P = 0.000). Hemodynamic parameters were similar and statistically not significant. Need for first analgesic requirement was after 262.88 ± 21.11 min in group M and 193.25 ± 17.74 min in the group S (P = 0.000). Mean dosage of tramadol needed in first 24 h was less in group M (190 ± 30.38 mg vs. 265 ± 48.30 mg, P = 0.000).

Conclusion:

Use of intravenous magnesium with spinal anesthesia reduces post-operative pain and analgesic consumption.

Hyperacute therapies for childhood stroke: a case report and review of the literature

Objective. The optimal management of pediatric patients with arterial ischemic stroke (AIS) is not known. Despite this, goal-oriented, time-sensitive therapies geared to rapid reestablishment of arterial blood flow are occasionally applied with beneficial effects. The inconsistent approach to AIS is in part due to a lack of knowledge and preparedness. Methods. Case report of a 12-year-old male with right middle cerebral artery (MCA) occlusion resulting in dense left hemiplegia and mutism and review of the literature. Intervention(s). Mechanical thrombectomy, intra-arterial administration of rt-PA, vasodilators, and platelet inhibitors, and systemic anticoagulation and subsequent critical care support. Results. Restoration of right MCA blood flow and complete resolution of neurologic deficits. Conclusion. We report the gratifying outcome of treatment of a case of AIS in a pediatric patient treated with hyperacute therapies geared to arterial recanalization and subsequent neurologic critical care and review the pertinent literature. Guidelines for the emergency room management of pediatric AIS from prospective, randomized trials are needed.

Alcohol and arrhythmias: a comprehensive review

The use of alcohol as a social lubricant has been ubiquitous in human societies since ancient times. It has also long been recognized that alcohol produces undesirable cardiovascular effects, especially when imbibed in excess. Numerous investigators have noted a causal relationship between alcohol and arrhythmias, as well as sudden cardiac death. We have undertaken a comprehensive review of the literature on alcohol as a potential trigger for arrhythmias. We have reviewed the major epidemiological studies undertaken on this subject. We have also explored pathophysiological mechanisms that drive the arrythmogenic effects of alcohol. In conclusion, although there is definite proof in the literature to implicate alcohol as a culprit in arrhythmias, the relationship is complex.

Effect of Mg ions on efficiency of gene electrotransfer and on cell electropermeabilization

Gene electrotransfer is a promising nonviral method that enables DNA to be transferred into living cells with electric pulses. However, there are many parameters that determine gene electrotransfer efficiency. One of the steps involved in gene electrotransfer is interaction of DNA with the cell membrane. Divalent cations in the electroporative media can influence the anchoring of DNA to the cell membrane and by that gene electrotransfer efficiency. Here we report the effect of different concentrations of Mg2+ on electropermeabilization for small molecule (propidium iodide), gene electrotransfer and viability of the cells. We also used TOTO-1 dye to visualize DNA-cell membrane interaction for different [Mg]. For this purpose, we used different electroporative media with increasing [Mg]. Our study shows that higher [Mg] lead to higher electropermeabilization for propidium iodide and higher viability, while causing lower gene electrotransfer efficiency. Because we observed higher TOTO-1 labeled DNA at cell surface when using higher [Mg], we suggest that Mg2+ ions can bind DNA at cell surface at such strength that cannot pass into the cell during application of electric pulses, which can lead to lower gene transfection. There may also be other mechanisms involved, since there are many steps of gene electrotransfer on which Mg2+ ions can have an effect on. Our results also imply that membrane permeability changes are not sufficient for an efficient gene electrotransfer.

Magnesium sulphate as a technique of hypotensive anaesthesia

BACKGROUND

This randomized, double-blind, placebo-controlled study was designed to assess the effect of perioperatively administered i.v. magnesium sulphate as a technique of hypotensive anaesthesia.

METHODS

Sixty patients (25 female) undergoing functional endoscopic sinus surgery were included in two parallel groups. The magnesium group received magnesium sulphate 40 mg kg(-1) i.v. as a bolus before induction of anaesthesia and 15 mg kg(-1) h(-1) by continuous i.v. infusion during the operation. The same volume of isotonic solution was administered to the control group. Intraoperative bleeding was evaluated using a quality scale.

RESULTS

In the magnesium group, there was a reduction in surgical time [68.1 (15.6) min vs 88.1 (10.7) min], although the anaesthetic time was 10 min longer and thus presuming a prolongation in anaesthetic emergence. There was a significant reduction of blood loss [165 (19) ml vs 257 (21) ml]. The anaesthetic requirements (fentanyl, vercuronium and sevoflurane), mean arterial blood pressure (P<0.005) and heart rate (P<0.005) were also significantly reduced.

CONCLUSION

Magnesium sulphate led to a reduction in arterial pressure, heart rate, blood loss and duration of surgery. Furthermore, magnesium infusion alters anaesthetic dose requirements and emergence time.

Magnesium for the Treatment and Prevention of Atrial Tachyarrhythmias

Atrial tachyarrhythmias, including atrial fibrillation and flutter, occur frequently. Magnesium has been studied in the early conversion and prevention of atrial tachyarrhythmias, as well as in prevention of atrial tachyarrhythmias after coronary artery bypass graft surgery. Early conversion of atrial tachyarrhythmias and control of heart rate may be greater with magnesium than with common antiarrhythmic agents. Magnesium appears to be less useful for preventing recurrent atrial tachyarrhythmias; however, discrepancies in study methodologies make interpretation of results difficult. The use of magnesium for prevention of postoperative atrial arrhythmias has produced conflicting results, likely due to differences in study design. From the limited data available, magnesium appears to have some inherent antiarrhythmic properties. Certain patient populations may derive benefit from magnesium for the treatment of atrial tachyarrhythmias. However, further study is necessary to define the role of magnesium clearly for the treatment or prevention of atrial tachyarrhythmias.

Magnesium intake and risk of coronary heart disease among men

OBJECTIVE

Our aim in this study was to assess the relationship between magnesium intake and risk of coronary heart disease (CHD) among men.

METHODS

A total of 39,633 men in the Health Professionals Follow-up Study who returned a dietary questionnaire in 1986 were followed up for 12 years. Intakes of magnesium, zinc and potassium and other nutrients were assessed in 1986, 1990 and 1994. Total CHD incidence (nonfatal myocardial infarction (MI) and fatal CHD) was ascertained by biennial questionnaire and mortality surveillance confirmed by medical record review. Standard CHD risk factors were recorded biennially.

RESULTS

During 12 years of follow-up (414,285 person-years), we documented 1,449 cases of total CHD (1,021 non-fatal MI cases, and 428 fatal CHD). The age-adjusted relative risk (RR) of developing CHD in the highest quintile (median intake = 457 mg/day) compared with the lowest quintile (median intake = 269 mg/day) was 0.73 (95% CI 0.62-0.87, p for trend <0.0001). After controlling for standard CHD risk factors and dietary factors, the RR for developing CHD among men in the highest total magnesium intake quintile compared with those in the lowest was 0.82 (95% CI 0.65-1.05, p for trend = 0.08). For supplemental magnesium intake, the RR comparing the highest quintile to non-supplement users was 0.77 (95% CI 0.56-1.06, p for trend = 0.14).

CONCLUSIONS

These results suggest that intake of magnesium may have a modest inverse association with risk of CHD among men.

Involvement of the antiplatelet activity of magnesium sulfate in suppression of protein kinase C and the Na+/H+ exchanger

Magnesium sulfate is widely used to prevent seizures in pregnant women with hypertension. The aim of this study was to examine the inhibitory mechanisms of magnesium sulfate in platelet aggregation in vitro. In this study, magnesium sulfate concentration-dependently (0.6-3.0 mM) inhibited platelet aggregation in human platelets stimulated by agonists. Magnesium sulfate (1.5 and 3.0 mM) also concentration-dependently inhibited phosphoinositide breakdown and intracellular Ca+2 mobilization in human platelets stimulated by thrombin. Rapid phosphorylation of a platelet protein of M(r) 47,000 (P47), a marker of protein kinase C activation, was triggered by phorbol-12-13-dibutyrate (PDBu, 50 nM). This phosphorylation was markedly inhibited by magnesium sulfate (3.0 mM). Magnesium sulfate (1.5 and 3.0 mM) further inhibited PDBu-stimulated platelet aggregation in human platelets. The thrombin-evoked increase in pHi was markedly inhibited in the presence of magnesium sulfate (3.0 mM). In conclusion, these results indicate that the antiplatelet activity of magnesium sulfate may be involved in the following two pathways: (1) Magnesium sulfate may inhibit the activation of protein kinase C, followed by inhibition of phosphoinositide breakdown and intracellular Ca+2 mobilization, thereby leading to inhibition of the phosphorylation of P47. (2) On the other hand, magnesium sulfate inhibits the Na+/H+ exchanger, leading to reduced intracellular Ca+2 mobilization, and ultimately to inhibition of platelet aggregation and the ATP-release reaction.

Effect of Mg2SO4 Usage on Spinal Cord Ischemia-Reperfusion Injury: Electron Microscopic and Functional Evaluation

OBJECTIVES

To evaluate the effects of intravenous magnesium sulfate (Mg(2)SO(4)) administration on ischemia-reperfusion injury of the spinal cord.

MATERIAL AND METHODS

Sixteen rabbits were randomly assigned to the control (group I, 8 rabbits) and the study group (group II, 8 rabbits). The abdominal aorta was clamped for a period of 30 min followed by a reperfusion period of 60 min. The animals in group II received 0.25 ml/kg/h Mg(2)SO(4) intravenous infusion (15% Mg(2)SO(4)) throughout this procedure. The animals were then observed for 24 h after which their neurological states were evaluated and tissue samples obtained from the spinal cord were examined with electron microscopy.

RESULTS

Aortic pressure distal to the cross-clamp during the occlusion period was 9 +/- 3 mm Hg in group I and 19 +/- 6 mm Hg in group II. All animals in group I were paraplegic at the end of the study. In group II the neurological outcome of 1 animal was poor while the other 7 animals were neurologically in a good condition. Electron microscopic examinations of the spinal cord tissues of group I revealed severe injury but the ultrastructure was well preserved in group II.

CONCLUSIONS

Intravenous Mg(2)SO(4) administration may have protective effects on the ischemia-reperfusion injury of the spinal cord. We propose that Mg(2)SO(4) may be an additional protective pharmacological agent in thoracal and thoracoabdominal aortic surgery.

The therapeutic use of magnesium in anesthesiology, intensive care and emergency medicine: a review

PURPOSE

To review current knowledge concerning the use of magnesium in anesthesiology, intensive care and emergency medicine.

METHODS

References were obtained from Medline(R) (1995 to 2002). All categories of articles (clinical trials, reviews, or meta-analyses) on this topic were selected. The key words used were magnesium, anesthesia, analgesia, emergency medicine, intensive care, surgery, physiology, pharmacology, eclampsia, pheochromocytoma, asthma, and acute myocardial infarction.

PRINCIPLE FINDINGS

Hypomagnesemia is frequent postoperatively and in the intensive care and needs to be detected and corrected to prevent increased morbidity and mortality. Magnesium reduces catecholamine release and thus allows better control of adrenergic response during intubation or pheochromocytoma surgery. It also decreases the frequency of postoperative rhythm disorders in cardiac surgery as well as convulsive seizures in preeclampsia and their recurrence in eclampsia. The use of adjuvant magnesium during perioperative analgesia may be beneficial for its antagonist effects on N-methyl-D-aspartate receptors. The precise role of magnesium in the treatment of asthmatic attacks and myocardial infarction in emergency conditions needs to be determined.

CONCLUSIONS

Magnesium has many known indications in anesthesiology and intensive care, and others have been suggested by recent publications. Because of its interactions with drugs used in anesthesia, anesthesiologists and intensive care specialists need to have a clear understanding of the role of this important cation.

Magnesium in stroke treatment

Magnesium is involved in multiple physiological processes that may be relevant to cerebral ischaemia, including antagonism of glutamate release, NMDA receptor blockade, calcium channel antagonism, and maintenance of cerebral blood flow. Systemically administered magnesium at doses that double physiological serum concentration significantly reduces infarct volume in animal models of stroke, with a window of up to six hours after onset and favourable dose-response characteristics when compared with previously tested neuroprotective agents. Small clinical trials have reported benefit, but results are not statistically significant in systematic review. A large ongoing trial (IMAGES) will report in 2003-4 and further trials are planned.

Magnesium-enriched coronary sinus retroperfusion during acute coronary artery occlusion

BACKGROUND

The protective effect of coronary sinus retroperfusion in cases of ischaemic myocardium is clearly known. It restores the blood flow to the ischaemic tissue, reduces the infarct size, and improves the left ventricular pump function.

METHODS

In this study, we investigated the effects of coronary sinus retroperfusion with the addition of magnesium sulphate on myocardial haemodynamics. A total of sixteen animals were entered into the study and divided equally into four groups: group I, control group, left anterior descending (LAD) coronary artery occlusion only; group II, LAD artery occlusion and Mg SO infusion; group III, LAD occlusion and retrograde coronary sinus perfusion; and group IV, LAD occlusion, retrograde coronary sinus perfusion and Mg SO infusion.(4) (4)

RESULTS

Haemodynamic measurements were obtained throughout the study, at baseline, during the first and third hour of occlusion, and in the second, fourth and sixth hour of reperfusion. Although, the cardiac index was decreased in all groups, in the second hour of reperfusion it was significantly higher in groups III and IV compared to the control group. In the second hour of reperfusion cardiac index values were 56 +/- 5 and 63 +/- 6 ml/kg per min in groups III and IV respectively (P < 0.05) and as time passed this incremental change in groups III and IV became more apparent. In the fourth hour of reperfusion, group II showed significantly higher values than the control group. Group IV had higher values compared to group III at the fourth and sixth hours post-reperfusion. In general there were significant differences between groups II, III and IV at four and six hours post-reperfusion. The first derivative of pressure measured over time-the dP/dt value-was higher in groups III and IV compared to the control group in the first hour of occlusion (being 1650 +/- 55 and 1700 +/- 35 in groups III and IV respectively, and 1420 +/- 45 in the control group) and these differences continued throughout the occlusion and the reperfusion periods (P < 0.05). Group IV had the highest left ventricular stroke work index (LVSWI) values compared to the other groups in various pulmonary capillary wedge pressure (PCWP) measurements (P < 0.05). It was 0.78 g.m/kg at the 20 mmHg PCWP.

CONCLUSIONS

Magnesium, if administered in an antegrade direction had only a limited effect, whereas magnesium-enriched retrograde coronary sinus perfusions appeared to significantly protect the ischaemic myocardium against the hazardous effects of ischaemic reperfusion injury.

Magnesium metabolism after cardiac surgery in children

OBJECTIVE: To analyze magnesium metabolism in children after cardiac surgery. DESIGN: Prospective observational study. SETTING: Pediatric intensive care unit (PICU) of a university hospital. PATIENTS: A total of 42 children in the perioperative period of cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Determinations of serum magnesium (MgS), ultrafiltrable magnesium (MgU), intraerythrocytic magnesium, urinary magnesium, blood and urinary calcium, phosphorus, sodium, and blood and urinary creatinine were made in the operating room before surgery, at admission to the PICU, at 24 hrs, and at 3 and 5 days after surgery. The relationship with age, sex, diagnosis, type of surgery, arrhythmias, complications, length of stay in the PICU, and mortality was analyzed. MgS and MgU levels decreased after cardiac surgery (MgS before surgery, 0.74 +/- 0.09 mmol/L; MgS at admission to the PICU, 0.66 +/- 0.11 mmol/L; MgU before surgery, 0.56 +/- 0.06 mmol/L; MgU at admission to the PICU, 0.50 +/- 0.07 mmol/L; p <.0001 for both values). At admission to the PICU, 61.5% of the patients had MgS of <0.63 mmol/L, and 47.2% of the patients had an MgU of <0.46 mmol/L. MgS and MgU had increased by 24 hrs and showed further increases over the first 5 days after surgery. There were no significant changes in the intraerythrocytic magnesium levels in the postoperative period. Changes of MgS and MgU were greater after extracorporeal circulation than after closed surgery (p <.001). There was no correlation between MgS, MgU, or intraerythrocytic magnesium and other analytic and clinical parameters. No patient presented arrhythmias and none died. CONCLUSIONS: After cardiac surgery, and particularly after extracorporeal circulation surgery, children present with low MgS and MgU levels at admission to the PICU. MgS and MgU levels increase over the first 5 days after cardiac surgery. No relationship was found between magnesium levels and the postoperative course.

Magnesium sulfate as a tocolytic agent

Although magnesium sulfate is widely used as a tocolytic agent in the hope of preventing spontaneous preterm birth, there is a paucity of data from large well-designed randomized clinical studies demonstrating the efficacy of magnesium sulfate therapy. Given the potential for untoward side effects and the inherent risks of magnesium sulfate therapy, a thorough understanding of the potential risks and benefits of this agent is needed. To accomplish this understanding we have provided a detailed review the history, pharmacology, physiology, maternal/fetal side effects, and tocolytic efficacy of magnesium sulfate.

Prevention of ischemic spinal cord injury: comparative effects of magnesium sulfate and riluzole

PURPOSE

Excitotoxic mechanisms have been implicated in the pathophysiology of spinal cord ischemic injury induced by aortic cross-clamping. We investigated the effects of the anti-excitotoxic drugs magnesium sulfate (MgSO(4)) and riluzole in a rabbit model of spinal cord ischemia.

METHOD

The infrarenal aorta of New Zealand albino white rabbits (n = 68) was occluded for 40 minutes. Experimental groups included: a control group, which received only vehicle (n = 17); group A (n = 17), which received riluzole (8 mg/kg) before clamping; group B (n = 17), which received MgSO(4) (100 mg/kg) before clamping; and group C (n = 17), which received riluzole (8 mg/kg) and MgSO(4) (100 mg/kg) before clamping. Five additional rabbits had the same operation, but did not undergo aortic clamping (sham operation). The neurological status of the rabbits was assessed at 24 hours, 48 hours, and then daily for as long as 120 hours by using a modified Tarlov scale. The rabbits were killed at 24 hours (n = 3 per group), 48 hours (n = 4 per group), and 120 hours (n = 10 per group) postoperatively. Spinal cords were harvested for histopathologic and immunohistochemistry examinations for microtubule-associated protein-2 (MAP-2), a cytoskeletal protein specific from neurons.

RESULTS

No major adverse effect was observed with either riluzole or MgSO(4). All control rabbits became severely paraplegic. All riluzole-treated and MgSO(4)-treated animals had a better neurological status than control animals. Typical morphological changes characteristic of neuronal necrosis in the gray matter of control animals was demonstrated by means of the histopathological examination, whereas riluzole or magnesium prevented or attenuated necrotic phenomenons. Moreover, MAP-2 immunoreactivity was completely lost in control rabbits, whereas it was preserved, either completely or partially, in rabbits treated with riluzole or magnesium. Riluzole was more effective than MgSO(4) in preventing paraplegia caused by motor neuron injury (P <.01 ). Riluzole and MgSO(4) had no additive neuroprotective effect.

CONCLUSION

These results demonstrate that riluzole and, to a lesser extent, MgSO(4) may afford significant spinal cord protection in a setting of severe ischemia and may, therefore, be considered for clinical use during "high-risk" operations on the thoracic and thoracoabdominal aorta.

Magnesium in drinking water in relation to morbidity and mortality from acute myocardial infarction

We investigated the importance of magnesium and calcium in drinking water in relation to morbidity and mortality from acute myocardial infarction. Cases were men and women 50-74 years of age living in 18 Swedish municipalities who had suffered an acute myocardial infarction some time between October 1, 1994, and June 30, 1996. Controls were randomly selected from the same study base. We interviewed the surviving cases (N = 823) and controls (N = 853), focusing on risk factors for acute myocardial infarction. We collected individual data on drinking water levels of magnesium and calcium. We classified subjects by quartile of water magnesium or calcium levels. The total number of cases was similar in the four quartiles. The risk of death was 7.6% (95% confidence interval = 2.1-13.1) lower in the quartile with high magnesium levels (> or = 8.3 mg/liter). The odds ratio for death from acute myocardial infarction in relation to water magnesium was 0.64 (95% confidence interval = 0.42-0.97) for the highest quartile relative to the three lower ones. Multivariate analyses showed that other risk factors were not important confounders. For calcium, this study was inconclusive. The data suggest that magnesium in drinking water is associated with lower mortality from acute myocardial infarction, but not with the total incidence.

Cisplatin and hypomagnesemia

Hypomagnesemia is a well known side-effect in patients receiving cisplatin-containing chemotherapy. Cisplatin induces hypomagnesemia through its renal toxicity possibly by a direct injury to mechanisms of magnesium reabsorption in the ascending limb of the loop of Henle as well as the distal tubule. Since the magnesium reabsorption process still remains to be fully characterized, the effect by cisplatin on this process remains uncertain. Hypomagnesemia is a frequent complication to chemotherapy with cisplatin affecting up to 90% of patients if no corrective measures are initiated. The clinical importance of this hypomagnesemia remains uncertain. Possible symptoms of hypomagnesemia can be impossible to distinguish from symptoms related to the underlying disease or the treatment with chemotherapy. Existing studies on how to supplement magnesium during treatment with cisplatin have focused mainly on the effect on serum magnesium values and erythrocyte magnesium concentrations but both parameters are poor indicators of body magnesium stores. As long as the relationship between hypomagnesemia and possible complications thereof remains poorly elucidated, it seems reasonable to try to avoid hypomagnesemia. The best results seem to be provided by adding magnesium to the pre- and posthydration fluids.

Abnormal platelet Ca2+ handling accompanied by increased cytosolic free Mg2+ in essential hypertension

To test the hypothesis that abnormal platelet Ca2+ handling in essential hypertension results from cellular Mg2+ deficiency, cytosolic free Mg2+ concentration ([Mg2+]i) and Ca2+ metabolism were studied in mag-fura 2 and fura 2-loaded platelets from 30 essential hypertensive patients and 30 sex- and age-matched normotensive controls. Basal cytosolic free Ca2+ concentration ([Ca2+]i) and intracellular Ca2+ discharge capacity were higher in hypertensives than in normotensives (22 +/- 5 vs. 18 +/- 5 nM, P < 0.05; 743 +/- 250 vs. 624 +/- 144 nM, P < 0.05, respectively). The thrombin (0. 03-1.0 U/ml)-evoked [Ca2+]i response was also enhanced in platelets from hypertensives in both the absence and presence of extracellular Ca2+. However, basal [Mg2+]i was higher in hypertensives than in normotensives (437 +/- 110 vs. 353 +/- 85 microM, P < 0.05), whereas serum Mg2+ was similar in the two groups. These results oppose the Mg2+ deficiency hypothesis in platelets in essential hypertension.

Effect of chronic administration of magnesium sulfate on 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced neurotoxicity in mice

This investigation was aimed to study the effect of magnesium on 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced neurotoxicity in mice. Four groups of mice were given magnesium sulfate (MgSO4.7H2O) in drinking water at four different concentrations of 0.0 g/l (control), 2.5 g/l (low), 5.0 g/l (medium) and 10.0 g/l (high) respectively for a period of 16 weeks; these animals also received MPTP (30 mg/kg, intraperitoneally daily) during the last five days of Mg treatment. Other four groups of mice were given similar dose regimen of MgSO4 but received injections of saline instead of MPTP. Seventy-two hr after the last dose of MPTP, neurobehavioural studies including locomotor activity, pole climbing test and heart nociception test were performed and striata were collected for the analysis of dopamine. The results of this study show that treatment of mice with MgSO4 or MPTP individually has no effect on their behaviour. Concomitant administration of low dose of MgSO4 (2.5 g/l) along with MPTP produced increase in motor activity and latency to heat stimuli; whereas medium and high doses of MgSO4 in combination with MPTP produced opposite (as compared to low dose) effects resulting in a decrease in motor activity and latency to heat stimuli and increase in pole climbing time. However, MgSO4 dose-dependently exacerbated MPTP-induced depletion of striatal dopamine. The mortality was drastically increased (30-55%) in the animals receiving combined treatments of MPTP and MgSO4 as compared to the mice treated with MPTP alone (12%). This study clearly points towards the ability of MgSO4 to modify MPTP-induced neurotoxicity.

Hypomagnesemia inhibits nitric oxide release from coronary endothelium: protective role of magnesium infusion after cardiac operations

BACKGROUND

Postoperative hypomagnesemia is common in patients who have undergone cardiac operations and is associated with clinically significant morbidity resulting from atrial and ventricular dysrhythmias. Magnesium supplementation may increase the cardiac index in the early postoperative period.

METHODS

The action of the magnesium cation on coronary vascular reactivity was studied. Segments of canine epicardial coronary artery were suspended in organ chambers to measure isometric force (95% O2/5% CO2, 37 degrees C).

RESULTS

In coronary segments constricted with prostaglandin F2alpha (2 x 10[-6] mol/L), acetylcholine and adenosine diphosphate (10[-9] to 10[-4] mol/L) induced vasodilation in arteries with endothelium (n=10, each group; p < 0.05). Acetylcholine-mediated vasodilation was blocked by NG-monomethyl-L-arginine (10[-4] mol/L) and NG-nitro-L-arginine (10[-4] mol/L), two inhibitors of nitric oxide synthesis from L-arginine (n=10, p < 0.05). The removal of magnesium from the organ chamber solution impaired vasodilation in response to acetylcholine and adenosine diphosphate. However, normal endothelium-dependent vasodilation could be restored by return of magnesium to the bathing solution. Vascular relaxation in response to bradykinin (10[-9] to 10[-6] mol/L), which was found to induce endothelium-dependent vasodilation independent of nitric oxide production, was unaffected by magnesium removal (n=10).

CONCLUSIONS

Hypomagnesemia selectively impaired the release of nitric oxide from the coronary endothelium. Because nitric oxide is a potent endogenous nitro-vasodilator and inhibitor of platelet aggregation and adhesion, hypomagnesemia could promote vasoconstriction and coronary thrombosis in the early postoperative period.

Skeletal muscle magnesium and potassium by gender and hypertensive status

The relation between blood pressure and skeletal muscle magnesium and potassium, and the relation between these electrolytes and body mass index, blood lipids, blood glucose and plasma insulin concentrations were studied in 29 hypertensive and 21 normotensive men. In addition, a comparison was made between the normotensive men and 37 normotensive women regarding the concentrations of muscle potassium and magnesium. Mean skeletal muscle potassium concentration was lower and plasma insulin higher in hypertensive compared to normotensives. Systolic and diastolic blood pressures were inversely correlated to muscle potassium and positively correlated to insulin. Muscle magnesium was positively correlated to muscle potassium but not to blood pressure. Muscle magnesium was significantly higher in normotensive women, compared to normotensive men. Muscle potassium did not differ between the genders.

Calcium and magnesium in drinking water and risk of death from cerebrovascular disease

BACKGROUND AND PURPOSE

Many studies have demonstrated a negative association between mortality from cardiovascular or cerebrovascular diseases and water hardness. This report examines whether calcium and magnesium in drinking water are protective against cerebrovascular disease.

METHODS

All eligible cerebrovascular deaths (17133 cases) of Taiwan residents from 1989 through 1993 were compared with deaths from other causes (17133 controls), and the levels of calcium and magnesium in drinking water of these residents were determined. Data on calcium and magnesium levels in drinking water throughout Taiwan were obtained from the Taiwan Water Supply Corporation. The control group consisted of people who died from other causes, and the controls were pair matched to the cases by sex, year of birth, and year of death.

RESULTS

The adjusted odds ratios (95% confidence interval) were 0.75 (0.65 to 0.85) for the group with water magnesium levels between 7.4 and 13.4 mg/L and 0.60 (0.52 to 0.70) for the group with magnesium levels of 13.5 mg/L or more. After adjustment for magnesium levels in drinking water, there was no difference between the groups with different levels of calcium.

CONCLUSIONS

The results of the present study show that there is a significant protective effect of magnesium intake from drinking water on the risk of cerebrovascular disease. This is an important finding for the Taiwan water industry and human health.

Magnesium sulfate attenuates peroxide-induced vasoconstriction in the human placenta

OBJECTIVE

Magnesium sulfate is used to prevent convulsions in preeclamptic women. It acts as a calcium antagonist but may also stimulate prostacyclin. Because magnesium sulfate readily crosses the placenta, we evaluated whether it might have a beneficial effect on placental blood flow.

STUDY DESIGN

Isolated human placental cotyledons (n = 6) were perfused for 20-minute intervals with control Krebs-Ringer-bicarbonate buffer, 200 mumol/L t-butyl hydroperoxide, magnesium sulfate (6 mEq/L), peroxide plus magnesium sulfate, and peroxide plus magnesium sulfate plus calcium chloride (6.25 mEq/L). Peroxide perfusion was used to stimulate thromboxane to induce vasoconstriction. Fetal perfusion pressure was continually monitored. Maternal and fetal effluent samples were analyzed for thromboxane and prostacyclin by their stable metabolites, thromboxane B2 and 6-keto-prostaglandin F1 alpha.

RESULTS

Compared with control Krebs-Ringer-bicarbonate buffer perfusion, peroxide perfusion significantly increased (p < 0.05) vascular resistance (12.9 +/- 1.2 vs 21.1 +/- 2.6 mm Hg.min/ml, mean +/- SE) and thromboxane B2 secretion (fetal -0.22 +/- 0.08 vs 0.73 +/- 0.11 ng/min, maternal -1.5 +/- 0.4 vs 4.4 +/- 0.7 ng/min). Subsequent perfusion with magnesium sulfate significantly attenuated (p < 0.05) peroxide-induced vasoconstriction (15.1 +/- 1.7 mm Hg.min/ml), which was reversed by the addition of calcium (19.7 +/- 2.2 mm Hg.min/ml). Magnesium sulfate partially, but significantly (p < 0.05), inhibited the peroxide-induced increase in maternal thromboxane B2 secretion (3.2 +/- 0.6 ng/min) but not fetal thromboxane B2 secretion (1.1 +/- 0.3 ng/min). Magnesium sulfate did not affect 6-keto-prostaglandin F1 alpha secretion.

CONCLUSIONS

(1) Magnesium sulfate attenuates peroxide-induced vasoconstriction in the human placenta. (2) This effect is mediated by inhibition of thromboxane synthesis and antagonism of calcium.

Differential effects of extracellular Mg2+ on thrombin-induced and capacitative Ca2+ entry in human coronary arterial endothelial cells

Receptor-mediated and capacitative Ca2+ entry are the primary Ca2+ entry pathways in endothelial cells (ECs). The mechanisms for Ca2+ entry via these pathways have not been fully elucidated. In this study, the effect of low and high external Mg2+ concentrations on these Ca2+ entry pathways was examined in human coronary arterial ECs. External Mg2+ concentration did not affect cytosolic free Mg2+ concentration. After exposure to thrombin in Ca(2+)-free medium, addition of Ca2+ to the medium caused a rise in cytosolic free Ca2+ concentration ([Ca2+]i), indicating thrombin-induced Ca2+ influx. Thrombin-induced Ca2+ influx was inhibited by not only low but also high external Mg2+ concentrations. After depletion of endoplasmic Ca2+ stores by thapsigargin, addition of Ca2+ to the medium induced an increase in [Ca2+]i, indicating capacitative Ca2+ entry. Capacitative entry was found to be accelerated by low external Mg2+ and inhibited by high external Mg2+ concentration. Results suggest that receptor-mediated Ca2+ influx requires external Mg2+ but is inhibited by increased external Mg2+ concentrations and that capacitative Ca2+ entry is reduced by external Mg2+ in human coronary arterial ECs.

Magnesium and the N-methyl-D-aspartate receptor antagonist dizocilpine maleate neither increase glucose use nor induce a 72-kilodalton heat shock protein expression in the immature rat brain

In adult rats N-methyl-D-aspartate receptor (NMDAR) antagonists increase glucose use and induce a 72-kD heat shock protein (HSP72) expression in limbic system areas that later undergo neuronal necrosis, which have limited the clinical development of these drugs. Dizocilpine maleate (MK-801) and magnesium sulfate (MgSO4) reduce hypoxic-ischemic brain injury in immature animals, but the effects on HSP72 expression and glucose use are unknown. Seven-day-old rats received injections of either vehicle (control), 0.5 or 1.0 mg/kg MK-801, or 2 or 4 mmol/kg MgSO4. Glucose utilization was measured with the deoxyglucose method, 30 min, 48 h, and 4 d after injection. HSP72 immunostaining was evaluated 4 or 24 h after injection. Both doses of MK-801 and 4 mmol/kg MgSO4 induced a temporary decrease in glucose use in the posterior cingulate and retrosplenial cortex, the CA1 and CA3 subfields of the hippocampus, the caudoputamen, and the parietal cortex. Doses of 2 mmol/kg MgSO4 did not affect glucose use in any structure. Neuronal HSP72 expression was not found in any drug-treated rats. In conclusion, neither MK-801 nor MgSO4 increased glucose use in the limbic system and did not induce HSP72 expression, suggesting that NMDAR antagonists lack direct neurotoxicity in the immature brain.

Magnesium deficiency and cardiogenic shock after cardiopulmonary bypass

Magnesium is an important cation that has a key role in cellular processes of energy transfer and utilization involving adenosine triphosphate, and influences cell membrane functions. Its antiarrhythmic properties are well-known and it is widely recognized as an adjunct for the treatment of arrhythmias after myocardial infarction and cardiopulmonary bypass. Magnesium may influence hemodynamic performance through its effects on vascular tone, modulation of intracellular calcium, regulation of catecholamine activity, and its essential role in adenosine triphosphate metabolism. The potential for magnesium deficiency to affect cardiovascular performance may be especially relevant in ischemic states. We report a case of cardiogenic shock developing after cardiopulmonary bypass that was initially unresponsive to therapeutic intervention, but that resolved promptly after magnesium administration. The potential role of magnesium in enhancing hemodynamic performance is discussed, with a review of its cellular metabolic properties and activities.

Extracellular Mg2+ inhibits capacitative Ca2+ entry in vascular smooth muscle cells

BACKGROUND

Agonist-induced Ca2+ entry is thought to be mediated by capacitative Ca2+ entry other than L-type Ca2+ channels in vascular smooth muscle cells (VSMCs). The mechanism for capacitative Ca2+ entry has not been fully elucidated. Our objective was to examine the effect of external Mg2+ on capacitative Ca2+ entry in cultured rat aortic VSMCs.

METHODS AND RESULTS

Three doses of external Mg2+ concentration (nominally 0, 1, and 5 mmol/L) were used. After exposure to 1 mumol/L, angiotensin II (Ang II) in Ca(2+)-free medium, addition of Ca2+ to the medium caused an increase in cytosolic free Ca2+ concentration ([Ca2+]i), indicating Ang II-induced Ca2+ influx. This Ca2+ influx was attenuated in cells preincubated with high external Mg2+ concentrations or with 1 mumol/L nifedipine. After VSMCs in Ca(2+)-free medium were exposed to 1 mumol/L thapsigargin, which inhibits the sarcoplasmic reticulum Ca(2+)-ATPase and depletes Ca2+ stores, addition of Ca2+ to the medium induced an increase in [Ca2+]i, indicating capacitative Ca2+ entry. This entry pathway was found to be independent of dihydropyridine-sensitive Ca2+ channels and inhibited by increased external Mg2+ concentration. External Mg2+ concentration did not influence Ca2+ efflux across the plasma membrane after stimulation with Ang II plus thapsigargin.

CONCLUSIONS

Results suggest that in VSMCs, capacitative Ca2+ entry is reduced by external Mg2+. This mechanism may explain in part the inhibitory effect of external Mg2+ on Ca2+ handling.

[Clinico-electrophysiologic effects of magnesium, especially in supraventricular tachycardia]

Clinical electrophysiological effects of magnesium (Mg2+) are known for more than 60 years. Mg2+ is a cation to be found ubiquitously in the human body and is involved in more than 300 different enzymatic reactions. However, so far this ion has not been established as a standard therapeutic tool for the treatment of supraventricular tachyarrhythmia. This may be explained by the inconsistent efficacy of Mg2+, partly in relationship to a given plasma Mg(2+)-concentration, partly caused by the uncertainty regarding the dosage and injection rate or the unawareness of the clinical effects of the cation. Mg2+ influences myocardial metabolism by its effects on contractility and electrical activity. Both effects are closely linked. About 12% of cardiac Mg2+ is found in the mitochondria and 2 to 3% in the myofibrils. A large portion is incorporated in adenosin mono-, di- and triphosphate. Mg2+ affects intracellular calcium by inhibiting the influx of calcium into the myocyte through sarcolemmal channels, by modulation of cyclic AMP and by competing with calcium for binding to a single high affinity site on actin. Mg2+ has been linked to a naturally occurring calcium channel blocker. Furthermore Mg2+ blocks the outward current through some potassium channels resulting in an inward rectification of these channels. This suggests that internal magnesium functions as a potassium channel-blocking agent. Early afterdepolarizations are oscillations in the membrane potential and lead to triggered activity and therefore are the electrophysiological substrate of "torsade de pointes" type of ventricular flutter. Mg2+ is able to inhibit both early afterdepolarizations and tachyarrhythmias. Additionally Mg2+ interferes with the sodium-potassium-ATPase system by stabilizing the transmembrane gradient of both cations. Mg2+ deficiency alters this balance and leads to increased neuromuscular excitability. Digitalis is able to block the sodium-potassium-ATPase system, which can be cancelled by Mg2+. Thus the first clinical reports of the therapeutic use of Mg2+ refer to digitalis-induced atrial arrhythmia and ventricular ectopy which could be converted to sinus-rhythm or suppressed by the intravenous application of Mg2+ in 1935. Some years later, the first successful termination of paroxysmal supraventricular and ventricular tachycardia following application of 1.5 to 3 g of Mg2+ was published. But only in the late eighties, systematic studies of the electrophysiological effects of Mg2+ were performed and clinical use was first tested in random fashion in the nineties. Summarizing studies in older patients with different heart diseases and young healthy volunteers the most pronounced and clinically important effect seems to be related to the modulation of the AV node function. The prolongation of the PR interval by 7 to 12% without changing significantly heart rate, QRS duration and QT duration, can be considered a consistent and reproducible effect of Mg2+. In electrophysiological studies a prolongation of the AH interval by 8 to 18%, of the Wenckebach cycle length by up to 20% and of the refractory period of the AV node by 6 to 20% is usually observed, but no change of the retrograde conduction, or the HV interval can be found. Furthermore sinus node recovery time increases by 10% and sinuatrial conduction time by up to 25%. There is no significant effect on intraventricular conduction and atrial and ventricular refractory period. Additionally no significant effect on the anterograde and retrograde refractory period of accessory pathways could be measured; however in some cases (up to 40%) an anterograde block in the accessory pathway may be observed after intravenous Mg(2+)-injection. For the treatment of paroxysmal atrioventricular tachycardia like AV-nodal reentrant tachycardia or orthodromic atrioventricular reentrant tachycardia in WPW syndrome, Mg2+ has been applied in a limited number of recent prospective but uncontrolled studies. Recently, an

The influence of cardiopulmonary bypass on ionized magnesium in neonates, infants, and children undergoing repair of congenital heart lesions

The purpose of this study was to measure the ionized magnesium (iMg) concentrations in children undergoing the correction of congenital heart defects. iMg levels were measured in 115 consecutive patients at five sample periods: prebypass, onset of bypass, during rewarming, immediately postbypass, and 1 h postbypass using an ion-selective electrode of the NOVA-CRT 8 (Nova Biomedical, Watham, MA). The incidence of dysrythmias was noted. Patients were divided into two groups: those who received Plegisol as the cardioplegic solution and those who did not. This study demonstrates that iMg decreases with the onset of cardiopulmonary bypass (CPB) in patients who weigh < 10 kg. In the Plegisol group, all subgroups of patients demonstrated statistically higher iMg during the rewarming phase of CPB, immediately post-CPB, and 1 h post-CPB, when compared with control values. The probability of dysrhythmias in the Plegisol group was almost twice that of the non-Plegisol group. However, this did not reach statistical significance (P = 0.22). The results of our study demonstrate that the use of CPB on pediatric patients produces alterations in the iMg. The changes differ depending on both patient weight and the use of a magnesium-containing cardioplegic solution, exemplified here by Plegisol. The role of these changes in iMg on dysrhythmias could not be further evaluated.