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Ambrożej D, Adamiec A, Forno E, Orzołek I, Feleszko W, Castro-Rodriguez JA. Intravenous magnesium sulfate for asthma exacerbations in children: Systematic review with meta-analysis. Paediatr Respir Rev 2024:S1526-0542(24)00013-7. [PMID: 38395640 DOI: 10.1016/j.prrv.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Asthma is the most prevalent chronic disease in children and constitutes a significant healthcare burden. First-line therapy for acute asthma exacerbations is well established. However, secondary treatments, including intravenous magnesium sulfate (IV-MgSO4), remain variable due to scarcity of data on its efficacy and safety. OBJECTIVE To assess the effectiveness and safety of IV-MgSO4 as a second line of treatment in managing children with asthma exacerbations. METHODS We searched five databases from inception until April 2023 on randomized clinical trials of IV-MgSO4 in children with acute asthma exacerbations. The primary outcomes were hospitalization rate and length, and change in the severity score. Secondary outcomes included percentage increase in peak expiratory flow rate (PEFR), hospital re-admission rate, need and length for pediatric intensive care unit (PICU) treatment, and adverse effects. Meta-analysis was performed for three outcomes with estimated odds ratios (ORs) or mean differences (MDs) and 95% confidence intervals (CIs). RESULTS Eleven studies met the final criteria. In comparison to control, administration of IV-MgSO4 was associated with a reduced hospitalization risk (OR 0.15; 95%CI: 0.03, 0.73) in four studies, and improvement of lung function (MD 26.77% PEFR; 95%CI: 18.41, 54.79) in two studies. There were no significant differences in the length of stay between groups. Due to heterogeneity, a narrative synthesis of other outcomes was performed. CONCLUSION The use of IV-MgSO4 demonstrated a reduction in the hospitalization rate and PEFR improvement in children with asthma exacerbations. Adverse effects were rare. Further well-designed studies are needed to better determine the efficacy and safety profile of IV-MgSO4.
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Affiliation(s)
- Dominika Ambrożej
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland; Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Aleksander Adamiec
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland; Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Erick Forno
- Pediatric Pulmonology, Allergy/Immunology, and Sleep Medicine, Department of Pediatrics, Indiana University, Riley Hospital for Children, Indianapolis, IN, USA
| | - Izabela Orzołek
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Feleszko
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Jose A Castro-Rodriguez
- Department of Pediatric Pulmonology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Saglietti F, Girombelli A, Marelli S, Vetrone F, Balzanelli MG, Tabaee Damavandi P. Role of Magnesium in the Intensive Care Unit and Immunomodulation: A Literature Review. Vaccines (Basel) 2023; 11:1122. [PMID: 37376511 DOI: 10.3390/vaccines11061122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
Both the role and the importance of magnesium in clinical practice have grown considerably in recent years. Emerging evidence suggests an association between loss of magnesium homeostasis and increased mortality in the critical care setting. The underlying mechanism is still unclear, but an increasing number of in vivo and in vitro studies on magnesium's immunomodulating capabilities may shed some light on the matter. This review aims to discuss the evidence behind magnesium homeostasis in critically ill patients, and its link with intensive care unit mortality via a likely magnesium-induced dysregulation of the immune response. The underlying pathogenetic mechanisms, and their implications for clinical outcomes, are discussed. The available evidence strongly supports the crucial role of magnesium in immune system regulation and inflammatory response. The loss of magnesium homeostasis has been associated with an elevated risk of bacterial infections, exacerbated sepsis progression, and detrimental effects on the cardiac, respiratory, neurological, and renal systems, ultimately leading to increased mortality. However, magnesium supplementation has been shown to be beneficial in these conditions, highlighting the importance of maintaining adequate magnesium levels in the intensive care setting.
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Affiliation(s)
- Francesco Saglietti
- Santa Croce and Carle Hospital, Department of Emergency and Critical Care, 12100 Cuneo, Italy
| | - Alessandro Girombelli
- Division of Anesthesiology, Department of Anesthesiology, Intensive care and Emergency Medicine, Ospedale Regionale di Lugano, 69000 Lugano, Switzerland
| | - Stefano Marelli
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy
| | - Francesco Vetrone
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy
| | - Mario G Balzanelli
- Department of Prehospital Emergency Medicine, ASL TA, Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy
| | - Payam Tabaee Damavandi
- Department of Neurology, Fondazione IRCCS San Gerardo dei Tintori, School of Medicine and Surgery, Milan Center for Neuroscience, University of Milano-Bicocca, 20900 Monza, Italy
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Awlad Thani SS, Alkhan AA, Al-Farsi MY, Al Kamzari AM. Safety and Effectiveness of Prolonged Magnesium Sulfate (MgSO4) Infusion for Asthma Exacerbation in Children. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1742674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractThe objective of this study was to assess the safety and describe treatment details of prolonged magnesium sulfate (MgSO4) infusion for children with asthma exacerbation. A retrospective cross-sectional study included children under 13 years of age who were admitted with asthma exacerbation and received at least 24 hours of MgSO4 infusion. One hundred children were included. No patient developed serious adverse events. The mean infusion duration was 74.2 hours. Eighty-nine percent recovered with no other bronchodilator infusions, and 94% did not require respiratory support escalation. Prolonged MgSO4 infusion is safe at a maximum dose of 30 mg/kg/h and may be beneficial for children with asthma exacerbation.
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Erumbala G, Anzar S, Tonbari A, Salem R, Powell C. Stating the obvious: intravenous magnesium sulphate should be the first parenteral bronchodilator in paediatric asthma exacerbations unresponsive to first-line therapy. Breathe (Sheff) 2022; 17:210113. [PMID: 35035570 PMCID: PMC8753647 DOI: 10.1183/20734735.0113-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/05/2021] [Indexed: 11/05/2022] Open
Abstract
What is the most appropriate second-line intravenous bronchodilator treatment when a child with a severe asthma attack is not responsive to initial inhaled therapy? The second-line treatment options for acute asthma include parenteral β2-agonists, methylxanthine and magnesium sulphate (MgSO4). There is a poor evidence-base to inform this decision. This review argues that intravenous MgSO4 is the obvious treatment of choice for this situation as the initial treatment based on current knowledge. We describe the mode of action, scope and limitations of MgSO4, safety profile, economic impact, comparisons of the alternatives, and finally, what the guidelines say. This review explores the suitability of intravenous MgSO4 as a pragmatic and safe initial second-line therapy for children unresponsive to initial asthma management.
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Affiliation(s)
| | - Sabu Anzar
- Pediatric Emergency Dept, Sidra Medicine, Doha, Qatar
| | - Amjad Tonbari
- Pediatric Emergency Dept, Sidra Medicine, Doha, Qatar
| | - Ramadan Salem
- Pediatric Emergency Dept, Sidra Medicine, Doha, Qatar
| | - Colin Powell
- Pediatric Emergency Dept, Sidra Medicine, Doha, Qatar.,Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Johnson PN, Drury AS, Gupta N. Continuous Magnesium Sulfate Infusions for Status Asthmaticus in Children: A Systematic Review. Front Pediatr 2022; 10:853574. [PMID: 35391743 PMCID: PMC8983002 DOI: 10.3389/fped.2022.853574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Magnesium sulfate is a second-tier therapy for asthma exacerbations in children; guidelines recommend a single-dose to improve pulmonary function and decrease the odds of admission to the in-patient setting. However, many clinicians utilize prolonged magnesium sulfate infusions for children with refractory asthma. The purpose of this review is to describe the efficacy and safety of magnesium sulfate infusions administered over ≥ 1 h in children with status asthmaticus. METHODS Medline was searched using the keywords "magnesium sulfate" and "children." Articles evaluating the use of magnesium sulfate infusions for ≥1 h published between 1946 and August 2021 were included. Published abstracts were not included because of lack of essential details. All articles were screened by two reviewers. RESULTS Eight reports including 447 children were included. The magnesium regimens evaluated included magnesium delivered over 1 h (n = 148; 33.1%), over 4-5 h (n = 105; 23.5%), and over >24 h (n = 194; 43.4%). Majority of patients received a bolus dose of 25-75 mg/kg/dose prior to initiation of a prolonged infusion (n = 299; 66.9%). For the patients receiving magnesium infusions over 4-5 h, the dosing regimen varied between 40 and 50 mg/kg/h. For those receiving magnesium infusions >24 h, the dosing varied between 18.4 and 25 mg/kg/h for a duration between 53.4 and 177.5 h. Only three reports including 186 patients (41.6%) included an evaluation of clinical outcomes including evaluation of lung function parameters, reduction in PICU transfers, and/or decrease in emergency department length of stay. Five reports including 261 patients (58.4%) evaluated magnesium serum concentrations. In most reports, the goal concentrations were between 4 and 6 mg/dL. Only 3 (1.1%) out of the 261 patients had supratherapeutic magnesium concentrations. The only reports finding adverse events attributed to magnesium were noted in those receiving infusions for >24 h. Clinically significant adverse events included hypotension (n = 74; 16.6%), nausea/vomiting (n = 35; 7.8%), mild muscle weakness (n = 22; 4.9%), flushing (n = 10; 2.2%), and sedation (n = 2; 0.4%). CONCLUSION Significant variability was noted in magnesium dosing regimens, with most children receiving magnesium infusions over >4 h. Most reports did not assess clinical outcomes. Until future research is conducted, the use of prolonged magnesium sulfate infusions should be reserved for refractory asthma therapy.
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Affiliation(s)
- Peter N Johnson
- Department of Pharmacy, Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Anna Sahlstrom Drury
- Department of Pharmacy, University of Kentucky Chandler Medical Center, Lexington, KY, United States
| | - Neha Gupta
- Division of Critical Care Medicine, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, OK, United States
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Taher KW, Johnson PN, Miller JL, Neely SB, Gupta N. Efficacy and Safety of Prolonged Magnesium Sulfate Infusions in Children With Refractory Status Asthmaticus. Front Pediatr 2022; 10:860921. [PMID: 35757130 PMCID: PMC9218095 DOI: 10.3389/fped.2022.860921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES There is a paucity of data on the use of intravenous magnesium sulfate infusion in children with refractory status asthmaticus. The purpose of this study was to evaluate the efficacy and safety of prolonged magnesium sulfate infusion as an advanced therapy. METHODS This is a single center retrospective study of children admitted to our pediatric intensive care unit (PICU) with status asthmaticus requiring continuous albuterol. Treatment group included patients receiving magnesium for ≥4 h and control group included those on other therapies only. Patients were matched 1:4 based on age, sex, obesity, pediatric index of mortality III and pediatric risk of mortality III scores. Primary outcomes included PICU length of stay (LOS) and mechanical ventilation (MV) requirement. Secondary outcomes included mortality, extracorporeal membrane oxygenation (ECMO) requirement, analyses of factors associated with PICU LOS and MV requirement and safety of magnesium infusion. Logistic and linear regressions were employed to determine factors associated with MV requirement and PICU LOS, respectively. RESULTS Treatment and control groups included 27 and 108 patients, respectively. Median initial infusion rate was 15 mg/kg/hour, with median duration of 28 h. There was no difference in the MV requirement between the treatment and control groups [7 (25.9%) vs. 20 patients (18.5%), p = 0.39]. Median PICU LOS and ECMO use were significantly higher in treatment vs. control group [(3.63 vs. 1.09 days, p < 0.01) and (11.1 vs. 0%, p < 0.01), respectively]. No mortality difference was noted. On regression analysis, patients receiving ketamine and higher prednisone equivalent dosing had higher odds of MV requirement [OR 19.29 (95% CI 5.40-68.88), p < 0.01 and 1.099 (95% CI 1.03-1.17), p < 0.01, respectively]. Each mg/kg increase in prednisone equivalent dosing corresponded to an increase in PICU LOS by 0.13 days (95% CI 0.096-0.160, p < 0.01). Magnesium infusions were not associated with lower MV requirement or lower PICU LOS after controlling for covariates. Fourteen (51.9%) patients in the treatment group had an adverse event, hypotension being the most common. CONCLUSION Magnesium sulfate infusions were not associated with MV requirement, PICU LOS or mortality.
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Affiliation(s)
- Khalid W Taher
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Peter N Johnson
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Jamie L Miller
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Stephen B Neely
- Office of Instruction, Assessment, and Faculty/Staff Development, University of Oklahoma College of Pharmacy, Oklahoma City, OK, United States
| | - Neha Gupta
- Department of Pediatrics, Division of Critical Care Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, United States
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Anderson S, Farrington E. Magnesium Treatment in Pediatric Patients. J Pediatr Health Care 2021; 35:564-571. [PMID: 34479684 DOI: 10.1016/j.pedhc.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 10/20/2022]
Abstract
Pediatric patients may require magnesium replacement to treat life-threatening emergencies such as torsades de pointe or asthma exacerbations, as well as for the general replacement of magnesium in patients with hypomagnesemia. Clinicians must be aware of recommendations for magnesium administration as the route, dose, timing of administration, and formulation of magnesium can differ for each indication. It is imperative for clinicians to ensure that magnesium is appropriately administered to effectively treat the presenting indication and avoid adverse effects.
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Antoon JW, Hall M, Mittal V, Parikh K, Morse RB, Teufel RJ, Hogan AH, Shah SS, Kenyon CC. Intravenous Magnesium and Hospital Outcomes in Children Hospitalized With Asthma. Hosp Pediatr 2021; 11:785-793. [PMID: 34210764 DOI: 10.1542/hpeds.2020-004770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Use of intravenous magnesium (IVMg) for childhood asthma exacerbations has increased significantly in the last decade. Emergency department administration of IVMg has been shown to reduce asthma hospitalization, yet most children receiving IVMg in the emergency department are subsequently hospitalized. Our objective with the study was to examine hospital outcomes of children given IVMg for asthma exacerbations. METHODS We conducted a retrospective cohort study using data from the Pediatric Health Information System. We used propensity score matching to compare children who received IVMg on the first day of hospitalization with those who did not. Primary outcomes were initiation and duration of noninvasive positive pressure ventilation. Secondary outcomes included mechanical ventilation (MV) initiation, duration of MV, length of stay, and subsequent tertiary medication use. Primary analysis was restricted to children admitted to nonintensive care inpatient units. RESULTS Overall, 91 309 hospitalizations met inclusion criteria. IVMg was administered in 25 882 (28.4%) children. After propensity score matching, IVMg was not significantly associated with lower initiation (adjusted odds ratio 0.88; 95% confidence interval [CI] 0.74-1.05) or shorter duration of noninvasive positive pressure ventilation (rate ratio 0.94; 95% CI 0.87-1.02). Similarly, no significant associations were seen for MV initiation, MV duration, or length of stay. IVMg was associated with lower subsequent tertiary medication use (adjusted odds ratio 0.66; 95% CI 0.60-0.72). However, the association was lost when ipratropium was removed from the tertiary medication definition. CONCLUSIONS IVMg administration was not significantly associated with improved hospital outcomes. Further study is needed to inform the optimal indications and timing of magnesium use during hospitalization.
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Affiliation(s)
- James W Antoon
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee .,Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Vineeta Mittal
- Division of Pediatric Hospital Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kavita Parikh
- Hospitalist Division, Children's National Medical Center and School of Medicine, George Washington University, Washington, District of Columbia
| | | | - Ronald J Teufel
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Alexander H Hogan
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia and School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Gross Júnior M, Lago PM, Santana JCB, Biondo GF, Zandoná B, Chiaradia FDO, Carvalho PRA. Use of magnesium sulfate in continuous infusion in patients with severe acute asthma, in a pediatric emergency room. Pediatr Pulmonol 2021; 56:1924-1930. [PMID: 33831259 DOI: 10.1002/ppul.25393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 02/01/2021] [Accepted: 03/08/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Asthma is a chronic disease, of high prevalence, with important morbidity and that can lead to death in childhood. The use of intravenous magnesium sulfate has been indicated in cases refractory to the initial management with inhaled bronchodilators and corticosteroids. OBJECTIVE To evaluate the use of magnesium sulfate in continuous infusion (50 mg/kg/h in 4 h) in children with severe acute asthma in a pediatric emergency room. LOCATION Ten-bed general pediatric emergency room, university hospital, tertiary, in southern Brazil. PATIENTS All children over 2 years old with severe acute asthma refractory to the initial treatment who received a continuous infusion of magnesium sulfate at a dose of 50 mg/kg/h in 4 h, from April 2017 to October 2019. CONCLUSION Based on this study, the use of continuous intravenous magnesium sulfate proved to be well tolerated, leading to improved respiratory status, and can be considered as a satisfactory adjunctive therapy in the management of severe acute asthma.
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Affiliation(s)
- Milton Gross Júnior
- Child and Adolescent Health from the Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Patrícia Miranda Lago
- Pediatric Medicine and Child Health from the Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - João Carlos Batista Santana
- Child and Adolescent Health from the Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Bianca Zandoná
- Child and Adolescent Health from the Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Kapuscinski CA, Stauber SD, Hutchinson DJ. Escalation in Therapy Based on Intravenous Magnesium Sulfate Dosing in Pediatric Patients With Asthma Exacerbations. J Pediatr Pharmacol Ther 2020; 25:314-319. [PMID: 32461745 DOI: 10.5863/1551-6776-25.4.314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Our objective was to compare doses of intravenous magnesium sulfate and their association with escalations in therapy in children and adolescents presenting to the emergency department with an asthma exacerbation. METHODS This was a retrospective cohort study among children who received both magnesium sulfate and standard of care therapy for asthma exacerbations. A classification and regression tree (CART) analysis was performed to identify a breakpoint in dose in which a difference in the primary outcome was present. The primary endpoint was need for escalation in therapy within 24 hours of initial magnesium sulfate dose, defined as need for invasive or non-invasive mechanical ventilation or need for adjunctive therapy, that is, epinephrine, terbutaline, aminophylline, theophylline, ketamine, heliox, or additional doses of magnesium sulfate. RESULTS A total of 210 patients were included in the study. A CART analysis identified that a breakpoint of 27 mg/kg of magnesium was associated with a difference in the primary outcome of escalation in therapy in patients <40 kg. A subgroup analysis of patients <40 kg (n = 149) found patients who received magnesium doses >27 mg/kg had a higher incidence of the primary outcome of escalation in therapy, 15 patients (18.3%) versus 3 patients (4.5%) in the ≤27-mg/kg/dose group (p = 0.011). CONCLUSIONS Our results demonstrate larger doses of magnesium sulfate are associated with an increased need for invasive or non-invasive mechanical ventilation or need for adjunctive therapy(ies). Our findings are limited by confounding factors that may have influenced this outcome in our population.
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Werner K, Risko N, Burkholder T, Munge K, Wallis L, Reynolds T. Cost-effectiveness of emergency care interventions in low and middle-income countries: a systematic review. Bull World Health Organ 2020; 98:341-352. [PMID: 32514199 PMCID: PMC7265944 DOI: 10.2471/blt.19.241158] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries. METHODS Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies. RESULTS Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied. CONCLUSION We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.
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Affiliation(s)
- Kalin Werner
- Department of Surgery, Division of Emergency Medicine, F51-62, Old Main Building, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Nicholas Risko
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, United States of America (USA)
| | - Taylor Burkholder
- Department of Emergency Medicine, University of Southern California, Los Angeles, USA
| | - Kenneth Munge
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Lee Wallis
- Department of Surgery, Division of Emergency Medicine, F51-62, Old Main Building, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, 7925, South Africa
| | - Teri Reynolds
- Department for Clinical Services and Systems, Integrated Health Services, World Health Organization, Geneva, Switzerland
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12
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Intravenous Magnesium in Asthma Pharmacotherapy: Variability in Use in the PECARN Registry. J Pediatr 2020; 220:165-174.e2. [PMID: 32147221 DOI: 10.1016/j.jpeds.2020.01.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/06/2020] [Accepted: 01/29/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. STUDY DESIGN This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17 years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72 hours. RESULTS Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154 minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg. CONCLUSIONS In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.
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Rodríguez-Llamazares S, Arroyo-Hernández J, Rodríguez-Bautista H, Torre-Bouscoulet L. Interventions to Teach Inhaler Techniques, Risk Stratification of Asthma Exacerbations with Sputum Eosinophils, and High-Dose Infusion of Magnesium Sulfate for Severe Asthma. Am J Respir Crit Care Med 2019; 195:1528-1530. [PMID: 28379716 DOI: 10.1164/rccm.201609-1790rr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | - Luis Torre-Bouscoulet
- 2 Sleep Medicine Department, National Institute of Respiratory Diseases, Mexico City, Mexico
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14
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Zhu L, Yin H, Sun H, Qian T, Zhu J, Qi G, Wang Y, Qi B. The clinical value of aquaporin-4 in children with hand, foot, and mouth disease and the effect of magnesium sulfate on its expression: a prospective randomized clinical trial. Eur J Clin Microbiol Infect Dis 2019; 38:1343-1349. [PMID: 31028503 DOI: 10.1007/s10096-019-03559-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/04/2019] [Indexed: 10/26/2022]
Abstract
To evaluate the clinical value of aquaporin-4 (AQP-4) in hand, foot, and mouth disease (HFMD) and to evaluate therapeutic efficacy of magnesium sulfate (MgSO4) and its effect on AQP-4 expression. Children with HFMD were divided into a common group, a severe group and a critical group according to Chinese guidelines; children in the critical group were further divided into two subgroups: routine treatment group and MgSO4 group. Outcome measures included systolic blood pressure (SBP), Heart rate (HR), the levels of AQP-4, interleukin-6 (IL-6), norepinephrine (NE), and neuron-specific enolase (NSE). Serum AQP-4, IL-6, NE, and NSE levels varied significantly among the critical, severe, and common groups before and after treatment. There were no significant differences in AQP-4 levels in cerebrospinal fluid (CSF) between the critical and severe groups before and after treatment; however, CSF AQP-4 levels in these two groups were higher than those in the common group before treatment. Serum and CSF AQP-4 levels in convalescence decreased significantly in the critical and severe groups. SBP, HR and serum AQP-4, IL-6, NE, NSE levels, but not CSF AQP-4 levels, were significantly lower in MgSO4 group than in the routine treatment group. AQP-4 in serum, but not in CSF, is a candidate biomarker for evaluating the severity and prognosis of HFMD; MgSO4 can provide protection on children with critical HFMD.
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Affiliation(s)
- Lei Zhu
- Department of Intensive Care Unit, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Hong Yin
- Department of Pharmacy, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Haomiao Sun
- Department of Infectious Disease, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Tong Qian
- Department of Clinical Laboratory, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Junling Zhu
- Department of Intensive Care Unit, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Gongjian Qi
- Department of Intensive Care Unit, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yin Wang
- Department of Infectious Disease, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Boxiang Qi
- Department of Intensive Care Unit, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China.
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Gray CS, Powell CVE, Babl FE, Dalziel SR, Craig S. Variability of outcome measures in trials of intravenous therapy in acute severe paediatric asthma: a systematic review. Emerg Med J 2018; 36:225-230. [PMID: 30482777 DOI: 10.1136/emermed-2018-207929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/16/2018] [Accepted: 11/11/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the variability of primary and secondary outcomes used in trials of intravenous bronchodilators in children with acute severe paediatric asthma. METHODS Systematic search of MEDLINE, EMBASE, Cochrane CENTRAL and the WHO International Clinical Trials Registry Platform for randomised trials in children (less than18 years) with acute severe paediatric asthma comparing intravenous bronchodilator therapy to another treatment. Initial search was performed on 7 January 2016 with an updated search performed on 6 September 2018. Primary and secondary outcomes were collated. RESULTS We identified 35 published papers and four registered study protocols. 56 primary outcomes were found, the most common being a clinical asthma score (23/56; 41%). Other identified primary outcomes included bedside tests of respiratory function (11/56; 20%) and measures of length of stay (9/56; 16%). There were a total of 60 different secondary outcomes, the most common were various length of stay measures (24/60; 40%) and adverse events (11/60; 18%). CONCLUSION Studies comparing intravenous treatment modalities for children with acute severe paediatric asthma exhibit great variation in the type, number and timing of outcome measures used. There are no patient or family-specific outcomes reported. There is a need to develop international consensus. TRIAL REGISTRATION NUMBER CRD42017055331.
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Affiliation(s)
- Charmaine S Gray
- Emergency Department, Women's and Children's Hospital, University of Adelaide, North Adelaide, South Australia, Australia
| | - Colin V E Powell
- Emergency Department, Sidra Medical and Research Center, Doha, Qatar.,Emergency Department, Weill Cornell University, Doha, Qatar.,School of Medicine, Cardiff University, Cardiff, UK
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Simon Craig
- Monash Emergency Research Collaborative, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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What Is the Role for Magnesium to Treat Severe Pediatric Asthma Exacerbations? CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Knightly R, Milan SJ, Hughes R, Knopp‐Sihota JA, Rowe BH, Normansell R, Powell C. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database Syst Rev 2017; 11:CD003898. [PMID: 29182799 PMCID: PMC6485984 DOI: 10.1002/14651858.cd003898.pub6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Asthma exacerbations can be frequent and range in severity from mild to life-threatening. The use of magnesium sulfate (MgSO₄) is one of numerous treatment options available during acute exacerbations. While the efficacy of intravenous MgSO₄ has been demonstrated, the role of inhaled MgSO₄ is less clear. OBJECTIVES To determine the efficacy and safety of inhaled MgSO₄ administered in acute asthma. SPECIFIC AIMS to quantify the effects of inhaled MgSO₄ I) in addition to combination treatment with inhaled β₂-agonist and ipratropium bromide; ii) in addition to inhaled β₂-agonist; and iii) in comparison to inhaled β₂-agonist. SEARCH METHODS We identified randomised controlled trials (RCTs) from the Cochrane Airways Group register of trials and online trials registries in September 2017. We supplemented these with searches of the reference lists of published studies and by contact with trialists. SELECTION CRITERIA RCTs including adults or children with acute asthma were eligible for inclusion in the review. We included studies if patients were treated with nebulised MgSO₄ alone or in combination with β₂-agonist or ipratropium bromide or both, and were compared with the same co-intervention alone or inactive control. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial selection, data extraction and risk of bias. We made efforts to collect missing data from authors. We present results, with their 95% confidence intervals (CIs), as mean differences (MDs) or standardised mean differences (SMDs) for pulmonary function, clinical severity scores and vital signs; and risk ratios (RRs) for hospital admission. We used risk differences (RDs) to analyse adverse events because events were rare. MAIN RESULTS Twenty-five trials (43 references) of varying methodological quality were eligible; they included 2907 randomised patients (2777 patients completed). Nine of the 25 included studies involved adults; four included adult and paediatric patients; eight studies enrolled paediatric patients; and in the remaining four studies the age of participants was not stated. The design, definitions, intervention and outcomes were different in all 25 studies; this heterogeneity made direct comparisons difficult. The quality of the evidence presented ranged from high to very low, with most outcomes graded as low or very low. This was largely due to concerns about the methodological quality of the included studies and imprecision in the pooled effect estimates. Inhaled magnesium sulfate in addition to inhaled β₂-agonist and ipratropiumWe included seven studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, results were inconsistent overall and the largest study reporting this outcome found no between-group difference at 60 minutes (MD -0.3 % predicted peak expiratory flow rate (PEFR), 95% CI -2.71% to 2.11%). Admissions to hospital at initial presentation may be reduced by the addition of inhaled magnesium sulfate (RR 0.95, 95% CI 0.91 to 1.00; participants = 1308; studies = 4; I² = 52%) but no difference was detected for re-admissions or escalation of care to ITU/HDU. Serious adverse events during admission were rare. There was no difference between groups for all adverse events during admission (RD 0.01, 95% CI -0.03 to 0.05; participants = 1197; studies = 2). Inhaled magnesium sulfate in addition to inhaled β₂-agonistWe included 13 studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, none of the pooled results showed a conclusive benefit as measured by FEV1 or PEFR. Pooled results for hospital admission showed a point estimate that favoured the combination of MgSO₄ and β₂-agonist, but the confidence interval includes the possibility of admissions increasing in the intervention group (RR 0.78, 95% CI 0.52 to 1.15; participants = 375; studies = 6; I² = 0%). There were no serious adverse events reported by any of the included studies and no between-group difference for all adverse events (RD -0.01, 95% CI -0.05 to 0.03; participants = 694; studies = 5). Inhaled magnesium sulfate versus inhaled β₂-agonistWe included four studies in this comparison. The evidence for the efficacy of β₂-agonists in acute asthma is well-established and therefore this could be considered a historical comparison. Two studies reported a benefit of β₂-agonist over MgSO₄ alone for PEFR and two studies reported no difference; we did not pool these results. Admissions to hospital were only reported by one small study and events were rare, leading to an uncertain result. No serious adverse events were reported in any of the studies in this comparison; one small study reported mild to moderate adverse events but the result is imprecise. AUTHORS' CONCLUSIONS Treatment with nebulised MgSO₄ may result in modest additional benefits for lung function and hospital admission when added to inhaled β₂-agonists and ipratropium bromide, but our confidence in the evidence is low and there remains substantial uncertainty. The recent large, well-designed trials have generally not demonstrated clinically important benefits. Nebulised MgSO₄ does not appear to be associated with an increase in serious adverse events. Individual studies suggest that those with more severe attacks and attacks of shorter duration may experience a greater benefit but further research into subgroups is warranted.Despite including 24 trials in this review update we were unable to pool data for all outcomes of interest and this has limited the strength of the conclusions reached. A core outcomes set for studies in acute asthma is needed. This is particularly important in paediatric studies where measuring lung function at the time of an exacerbation may not be possible. Placebo-controlled trials in patients not responding to standard maximal treatment, including inhaled β₂-agonists and ipratropium bromide and systemic steroids, may help establish if nebulised MgSO₄ has a role in acute asthma. However, the accumulating evidence suggests that a substantial benefit may be unlikely.
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Affiliation(s)
| | | | - Rodney Hughes
- Sheffield Teaching HospitalsDepartment of Respiratory MedicineSheffieldUK
| | | | - Brian H Rowe
- University of AlbertaDepartment of Emergency MedicineRoom 1G1.43 Walter C. Mackenzie Health Sciences Centre8440 112th StreetEdmontonABCanadaT6G 2B7
- University of AlbertaSchool of Public HeathEdmontonCanada
| | - Rebecca Normansell
- St George's, University of LondonCochrane Airways, Population Health Research InstituteLondonUKSW17 0RE
| | - Colin Powell
- Cardiff UniversityDepartment of Child Health, The Division of Population Medicine, The School of MedicineCardiffUK
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Irazuzta JE, Chiriboga N. Magnesium sulfate infusion for acute asthma in the emergency department. J Pediatr (Rio J) 2017; 93 Suppl 1:19-25. [PMID: 28754601 DOI: 10.1016/j.jped.2017.06.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To describe the role of intravenous magnesium sulfate (MgSO4) as therapy for acute severe asthma in the pediatric emergency department (ED). SOURCE Publications were searched in the PubMed and Cochrane databases using the following keywords: magnesium AND asthma AND children AND clinical trial. A total of 53 publications were retrieved using this criteria. References of relevant articles were also screened. The authors included the summary of relevant publications where intravenous magnesium sulfate was studied in children (age <18 years) with acute asthma. The NAEPP and Global Initiative for Asthma expert panel guidelines were also reviewed. SUMMARY OF THE DATA There is a large variability in the ED practices on the intravenous administration of MgSO4 for severe asthma. The pharmacokinetics of MgSO4 is often not taken into account with a consequent impact in its pharmacodynamics properties. The cumulative evidence points to the effectiveness of intravenous MgSO4 in preventing hospitalization, if utilized in a timely manner and at an appropriate dosage (50-75mg/kg). For every five children treated in the ED, one hospital admission could be prevented. Another administration modality is a high-dose continuous magnesium sulfate infusion (HDMI) as 50mg/kg/h/4h (200mg/kg/4h). The early utilization of HDMI for non-infectious mediated asthma may be superior to a MgSO4 bolus in avoiding admissions and expediting discharges from the ED. HDMI appears to be cost-effective if applied early to a selected population. Intravenous MgSO4 has a similar safety profile than other asthma therapies. CONCLUSIONS Treatment with intravenous MgSO4 reduces the odds of hospital admissions. The use of intravenous MgSO4 in the emergency room was not associated with significant side effects or harm. The authors emphasize the role of MgSO4 as an adjunctive therapy, while corticosteroids and beta agonist remain the primary acute therapeutic agents.
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Affiliation(s)
- Jose Enrique Irazuzta
- Wolfson Children's Hospital, Jacksonville, United States; University of Florida, Jacksonville, United States.
| | - Nicolas Chiriboga
- Wolfson Children's Hospital, Jacksonville, United States; University of Florida, Jacksonville, United States
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19
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Irazuzta JE, Chiriboga N. Magnesium sulfate infusion for acute asthma in the emergency department. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2017. [DOI: 10.1016/j.jpedp.2017.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Shein SL, Speicher RH, Rotta AT. Reply to: Contemporary treatment of children with critical and near-fatal asthma. Rev Bras Ter Intensiva 2017; 28:358-359. [PMID: 27737429 PMCID: PMC5051201 DOI: 10.5935/0103-507x.20160064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Steven L Shein
- Divisão de Terapia Intensiva Pediátrica, UH Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Richard H Speicher
- Divisão de Terapia Intensiva Pediátrica, UH Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Alexandre T Rotta
- Divisão de Terapia Intensiva Pediátrica, UH Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Colleti Junior J, Carvalho WBD. To: Contemporary treatment of children with critical and near-fatal asthma. Rev Bras Ter Intensiva 2017; 28:356-357. [PMID: 27737422 PMCID: PMC5051200 DOI: 10.5935/0103-507x.20160063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- José Colleti Junior
- Unidade de Terapia Intensiva pediátrica, Hospital Santa Catarina, São Paulo, SP, Brazil
| | - Werther Brunow de Carvalho
- Terapia Intensiva/Neonatologia, Instituto da Criança, Departamento de Pediatria, Universidade de São Paulo, São Paulo, SP, Brazil
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Abstract
PURPOSE OF REVIEW Herein, we review the current guidelines for the management of children with an acute asthma exacerbation. We focus on management in the emergency department, inpatient, and ICU settings. RECENT FINDINGS The most recent statistics show that the prevalence of asthma during childhood has decreased in certain demographic subgroups and plateaued in other subgroups. However, acute asthma accounts for significant healthcare expenditures. Although there are few, if any, newer therapeutic agents available for management of acute asthma exacerbations, several reports leveraging quality improvement science have shown significant reductions in costs of care as well as improvements in outcome. SUMMARY Asthma is one of the most common chronic conditions in children and the most common reason that children are admitted to the hospital. Nevertheless, the evidence to support specific agents in the management of acute asthma exacerbations is surprisingly limited. The management of acute exacerbations focuses on reversal of bronchospasm, correction of hypoxia, and prevention of relapse and recurrence. Second-tier and third-tier agents are infrequently used outside of the ICU setting. Reducing the variation in treatment is likely to lead to lower costs and better outcomes.
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Affiliation(s)
- Erin K Stenson
- aDivisions of Critical Care Medicine bHospital Medicine, Cincinnati Children's Hospital Medical Center cDepartment of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Eizaga Rebollar R, García Palacios MV, Morales Guerrero J, Torres LM. Magnesium sulfate in pediatric anesthesia: the Super Adjuvant. Paediatr Anaesth 2017; 27:480-489. [PMID: 28244167 DOI: 10.1111/pan.13129] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 01/30/2023]
Abstract
Magnesium is an essential chemical element in all organisms, intervening in most cellular enzymatic reactions; thus, its importance in homeostasis and as a therapeutic tool in highly challenging patients such as pediatrics. The primary purpose of this paper was to review the role of magnesium sulfate as an adjuvant drug in pediatric anesthesia. This compound already has the scientific backing in certain aspects such as analgesia or muscle relaxation, but only theoretical or empirical backing in others such as organ protection or inflammation, where it seems to be promising. The multitude of potential applications in pediatric anesthesia, its high safety, and low cost make magnesium sulfate could be considered a Super Adjuvant.
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Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain
| | - María V García Palacios
- Department of Preventive Medicine and Public Health, Puerta del Mar University Hospital, Cádiz, Spain
| | - Javier Morales Guerrero
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain
| | - Luis M Torres
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain
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Vaiyani D, Irazuzta JE. Comparison of Two High-Dose Magnesium Infusion Regimens in the Treatment of Status Asthmaticus. J Pediatr Pharmacol Ther 2016; 21:233-8. [PMID: 27453701 DOI: 10.5863/1551-6776-21.3.233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the feasibility and safety of a simplified high-dose magnesium sulfate infusion (sHDMI) for the treatment of status asthmaticus. METHODS We retrospectively compared 2 different high-dose magnesium sulfate infusion regimens, as adjunctive treatment in status asthmatics, using data that were preciously collected. The initial high-dose, prolonged magnesium infusion (HDMI) regimen consisted of a loading dose of 75 mg/kg (weight ≤ 30 kg) or 50 mg/kg (weight > 30 kg) over a period of 30 to 45 minutes followed by a continuous infusion of 40 mg/kg/hr for an additional 4 hours. This was compared to the sHDMI regimen that consisted of 50 mg/kg/hr for 5 hours. No loading dose was given to the patients in the sHDMI arm. Obese patients were dosed by using ideal body weight. Physiologic parameters (i.e., heart rate, blood pressure, respiratory rate, oxygen saturation) and serum magnesium (SrMg) concentrations were monitored during administration of magnesium sulfate. RESULTS Nineteen patients receiving the initial HDMI regimen were compared with 10 patients who received the sHDMI regimen. There was no significant difference in SrMg concentrations or physiologic parameters between the 2 dose regimens. CONCLUSIONS The HDMI and sHDMI regimens both produced SrMg concentrations that are associated with bronchodilation. The safety profile was also similar for the 2 regimens. The unambiguity of sHDMI has the potential to reduce medication errors that are associated with calculation of the loading dose, product preparation, and ultimate administration.
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Affiliation(s)
- Danish Vaiyani
- Wolfson Children's Hospital/Baptist Health and University of Florida College of Medicine, Jacksonville, Florida
| | - Jose E Irazuzta
- Wolfson Children's Hospital/Baptist Health and University of Florida College of Medicine, Jacksonville, Florida
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The authors reply. Pediatr Crit Care Med 2016; 17:478-9. [PMID: 27144705 DOI: 10.1097/pcc.0000000000000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Griffiths B, Kew KM. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. Cochrane Database Syst Rev 2016; 4:CD011050. [PMID: 27126744 PMCID: PMC6599814 DOI: 10.1002/14651858.cd011050.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute asthma in children can be life-threatening and must be treated promptly in the emergency setting. Intravenous magnesium sulfate is recommended by various guidelines for cases of acute asthma that have not responded to first-line treatment with bronchodilators and steroids. The treatment has recently been shown to reduce the need for hospital admission for adults compared with placebo, but it is unclear whether it is equally effective for children. OBJECTIVES To assess the safety and efficacy of intravenous magnesium sulfate (IV MgSO4) in children treated for acute asthma in the emergency department (ED). SEARCH METHODS We identified studies by searching the Cochrane Airways Review Group Specialised Register up to 23 February 2016. We also searched ClinicalTrials.gov and reference lists of other reviews, and we contacted study authors to ask for additional information. SELECTION CRITERIA We included randomised controlled trials of children treated in the ED for exacerbations of asthma if they compared any dose of IV MgSO4 with placebo. DATA COLLECTION AND ANALYSIS Two review authors screened the results of the search and independently extracted data from studies meeting the inclusion criteria. We resolved disagreements through discussion and contacted study authors in cases of missing data and other uncertainties relating to the studies.We analysed dichotomous data as odds ratios and continuous data as mean differences, both using fixed-effect models. We assessed each study for risk of bias and rated the quality of evidence for each outcome with GRADE and presented the results in a 'Summary of findings' table. There was insufficient evidence to conduct the planned subgroup analyses. MAIN RESULTS Five studies (182 children) met the inclusion criteria, and four contributed data to at least one meta-analysis. The included studies were overall at low risk of bias, but our confidence in the evidence was generally low, mainly due to the small sample sizes. Treatment with IV MgSO4 reduced the odds of admission to hospital by 68% (odds ratio (OR) 0.32, 95% confidence interval (CI) 0.14 to 0.74; children = 115; studies = 3; I(2) = 63%). This result was based on data from just three studies including 115 children. Meta-analysis for the secondary outcomes was extremely limited by paucity of data. We performed meta-analysis for the outcome 'return to the emergency department within 48 hours', which showed a very imprecise effect estimate that was not statistically significant (OR 0.40, 95% CI 0.02 to 10.30; children = 85; studies = 2; I(2) = 0%). Side effects and adverse events were not consistently reported and meta-analysis was not possible, however few side effects or adverse events were reported. AUTHORS' CONCLUSIONS IV MgSO4 may reduce the need for hospital admission in children presenting to the ED with moderate to severe exacerbations of asthma, but the evidence is extremely limited by the number and size of studies. Few side effects of the treatment were reported, but the data were extremely limited.
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Affiliation(s)
- Benedict Griffiths
- Evelina London Children’s Hospital, St Thomas' HospitalWestminster Bridge RoadLondonUKSE1 7EH
| | - Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
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High-Dose Magnesium Infusions for Acute Severe Asthma in Children: If a Little Is Good, Is More Even Better? Pediatr Crit Care Med 2016; 17:177-8. [PMID: 26841033 DOI: 10.1097/pcc.0000000000000585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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