Hypermagnesemia induced by massive cathartic ingestion in an elderly woman without pre-existing renal dysfunction

Case report: Near-fatal hypermagnesemia resulting from the use of Epsom salts in a patient with normal renal function

Hypermagnesemia commonly occurs in patients with renal dysfunction. Diagnosing hypermagnesemia represents a challenge due to its rarity and the absence of routine monitoring of magnesium levels. Furthermore, the lack of awareness among clinicians regarding this uncommon condition frequently leads to delayed diagnoses. Few patients survive with a serum magnesium level exceeding 7 mmol/L. This article presents a case study of near-fatal hypermagnesemia resulting from the oral administration of Epsom salts in a patient with normal renal function. A 60-year-old female presented to the gastroenterology department on Oct. 6, 2023, with a 3-day history of black stools. She underwent subtotal gastrectomy in 2005 and has a stable history of nephrotic syndrome. To investigate the cause of her bleeding, electronic gastroscopy and colonoscopy were scheduled for Oct. 11, 2023. She experienced a sudden loss of consciousness 30 min after the ingestion of Epsom salts. The attending physician suspected a severe magnesium poisoning. She was promptly administered calcium gluconate, underwent tracheal intubation with ambu bag ventilation, and received early continuous renal replacement therapy (CRRT). Swift diagnosis and CRRT contributed to a reduction in her serum magnesium levels from an initial 8.71 mmol/L to 1.35 mmol/L, leading to a remarkable improvement in the toxic symptoms associated with hypermagnesemia. Subsequently, she was managed in the gastroenterology department, with gastroscopy revealing bleeding from the gastrointestinal anastomotic ulcer. Following conservative treatments including acid suppression, stomach protection, and hemostasis, her symptoms improved, and she was successfully discharged. This study aims to alert clinicians to the possibility of hypermagnesemia in individuals with normal renal function. Physicians should exercise caution when prescribing Epsom salts to patients with underlying gastrointestinal conditions. If necessary, alternative drug therapies may be considered to mitigate the risk of hypermagnesemia. Timely intervention is pivotal in averting life-threatening complications linked to hypermagnesemia.

Factors affecting the quality of bowel preparation for colonoscopy in hard-to-prepare patients: Evidence from the literature

Adequate bowel cleansing is critical for a high-quality colonoscopy because it affects diagnostic accuracy and adenoma detection. Nevertheless, almost a quarter of procedures are still carried out with suboptimal preparation, resulting in longer procedure times, higher risk of complications, and higher likelihood of missing lesions. Current guidelines recommend high-volume or low-volume polyethylene glycol (PEG)/non-PEG-based split-dose regimens. In patients who have had insufficient bowel cleansing, the colonoscopy should be repeated the same day or the next day with additional bowel cleansing as a salvage option. A strategy that includes a prolonged low-fiber diet, a split preparation regimen, and a colonoscopy within 5 h of the end of preparation may increase cleansing success rates in the elderly. Furthermore, even though no specific product is specifically recommended in the other cases for difficult-to-prepare patients, clinical evidence suggests that 1-L PEG plus ascorbic acid preparation are associated with higher cleansing success in hospitalized and inflammatory bowel disease patients. Patients with severe renal insufficiency (creatinine clearance < 30 mL/min) should be prepared with isotonic high volume PEG solutions. Few data on cirrhotic patients are currently available, and no trials have been conducted in this population. An accurate characterization of procedural and patient variables may lead to a more personalized approach to bowel preparation, especially in patients undergoing resection of left colon lesions, where intestinal preparation has a poor outcome. The purpose of this review was to summarize the evidence on the risk factors influencing the quality of bowel cleansing in difficult-to-prepare patients, as well as strategies to improve colonoscopy preparation in these patients.

The effect of medical biodegradable magnesium alloy in vivo degradation and bone response in a rat femur model with long-term fixation

BACKGROUND

It is of great significance to understand the effect of the different corrosion behaviors of magnesium (Mg) alloys manufactured using different casting methods and implanted with different methods on the long-term implantation to expand the application of Mg-based biomedical implants.

OBJECTIVE

The effects of four different casting and rolling speeds on the microstructure of an Mg-rare earth (Mg-Re) alloy were analyzed using electron backscatter diffraction (EBSD).

METHOD

Four Mg alloys were obtained using vertical two-roll casting (TRC) at 10 m/min, 16 m/min, 24 m/min, and 30 m/min, and their microstructure, corrosion behavior and bone reaction in vivo were studied.

RESULTS

The corrosion resistance of the alloy increases with an increase in casting speed and finer grain size of the cast-rolled parts. The Mg-Re alloys with TRC-10 m/min and TRC-30 m/min were selected for animal experiments. The two Mg alloys were made into metal rods and inserted into the rat femur to simulate the effect of Mg-Re on femoral healing under an injury condition. The rods were implanted for a long time to judge the effects of the Mg-Re alloy on the body. The TRC-30 m/min implants obtained highly mature new bone tissue in the case of bone injury.

CONCLUSION

The in vivo experiments showed that the corrosion resistance of the TRC-30 m/min implant was better than that of the TRC-10 m/min implant. After 32 weeks of implantation, there were no pathological changes in the liver, heart, or kidney of rats in the TRC-30 m/min group, and the cell structure was normal.

Iatrogenic Hypermagnesemia in a Patient With Preeclampsia Caused by Misinterpretation of the Magnesium Reporting Unit Following Magnesium Sulfate Administration

Because of the lack of standardization, different laboratories report plasma magnesium sulfate or magnesium level in different units, leading to errors in diagnosis and case management; especially when a patient's workup was done in a hospital and then transferred to another hospital. Failure to recognize or understand the reporting units can confuse clinicians and healthcare workers, leading to erroneous interpretations and, consequently, to misdiagnosis of hypermagnesemia or hypomagnesemia. In this report, we present a 32-year-old female patient at 31 weeks of gestation with a history of a multi-substance use disorder who was transferred to the hospital after taking 2.5mg of fentanyl. At the ER, her blood pressure and liver function tests were found to be high. Her albumin was 3.4 g/dl, aspartate transaminase (AST) was 104 IU/l, alanine transaminase (ALT) was 19 IU/l, and anaplastic lymphoma kinase (ALK) phosphatase was 148 IU/l; however, the renal function test was within the normal range. She had a few twitching movements. Her troponin I was high at 648 ng/L, and her B-type natriuretic peptide was 186.1 pg/mL, but her ECG showed a normal result. Magnesium was initiated on a 6 mg bolus, then 2 mg/dl due to preeclampsia concerns. She was transferred to another hospital ICU that used mEq/L as a reporting unit for magnesium and magnesium sulfate levels. The travel nurse did not alert the physician, thinking that magnesium sulfate was still within with therapeutic range of 4.8-8.4 mg/dL. However, considering 4.0-7.0 is the therapeutic range of magnesium sulfate utilizing mEq/L as a reporting unit instead of mg/dL, the patient was found to be at a supratherapeutic level, reaching up to 8.2 mEq/L. The physician discounted the magnesium sulfate. Her blood picture showed normocytic normochromic anemia. Her hemoglobin was 10.9 g/dl, her hematocrit was 33.8%, her mean corpuscular volume (MCV) was 92.5 fL, and her mean corpuscular hemoglobin (MCH) was 29.5 fL. Her platelets were within the normal range (169 10exp9/L). Her temperature was 99.6 F with increased white blood cells (17.7 10e9/L). The fetus was delivered via C-section on the third day of admission in the setting of persistently low fetal heart rates. The patient was extubated on the fourth day of admission and later transferred to the ward and discharged on the fifth day. Monitoring the magnesium level while administrating magnesium sulfate is essential to avoid iatrogenic hypermagnesemia. Utilizing different units at the same laboratory or across different laboratories could lead to the healthcare providers misinterpreting the result, which can lead to misdiagnosing iatrogenic hypermagnesemia. Therefore, standardizing magnesium units across the Clinical Laboratory Improvement Amendments (CLIA) and College of American Pathologists (CAP)-accredited laboratories is highly recommended. A unified unit reporting protocol will allow healthcare providers, constantly and correctly, to interpret the results and avoid misdiagnosing iatrogenic hypermagnesemia, and it will facilitate reporting and exchange of results among the different laboratories.

Ischemic Colitis Caused by Bowel Preparation for Colonoscopy

Background

Ischemic colitis is an adverse event which may occur during bowel preparation for colonoscopy. This study aims to clarify both the incidence and the risk factors of this complication.

Methods

This was a single-center, retrospective, observational study. All outpatients who were prescribed standardized preparation drugs for colonoscopy at the Kyoto Second Red Cross Hospital between November 2011 and March 2020 were included in the study. A split bowel preparation was carried out as follows; magnesium citrate with or without sodium picosulfate hydrate was/were used as a preparation drug on the day before the colonoscopy, and polyethylene glycol electrolyte solution or sodium phosphate was used on the morning of the endoscopic procedure. Patients were extracted from the electronic medical records and matched with the endoscopy database by examination date and hospital identification number. Following the endoscopic findings, both the incidence and risk factors for ischemic colitis arising after bowel preparation were examined.

Results

Among the 14,924 patients analyzed, ischemic colitis was observed in 14 patients (0.09%). Multivariate analysis revealed that old age (≥ 75 years old) and strong preparation (magnesium citrate with sodium picosulfate and polyethylene glycol electrolyte solution) for constipated patients were independent risk factors for ischemic colitis (odds ratio: 3.64 (95% confidence interval (CI): 1.36 - 9.77) and 4.27 (95% CI: 1.45 - 12.53), respectively).

Conclusions

The age 75 years and above and strong preparation for patients with constipation were independent risk factors for ischemic colitis prior to colonoscopy. Careful attention should be paid to bowel preparation before colonoscopy for patients aged ≥ 75 years and for those with constipation.

Safe and appropriate use of laxatives for colonoscopy

Background: Appropriate bowel preparation is essential for effective colonoscopy. Inadequate use of bowel preparation solutions reduces patient compliance, makes the detection of lesions such as adenoma difficult, and increases the risk of complication such as perforation. Current Concepts: A 4-L polyethylene glycol (PEG) solution can be safely used for bowel preparation, even in most individuals with underlying diseases. However, it requires a high preparation-volume intake and has poor patient compliance due to its unpleasant taste. Therefore, a 2- or 1- L sulfate-free, PEG-based laxative was developed to, reduce the amount of PEG and improve the taste. Furthermore, simethicon-containing laxative formulation was developed to eliminate gas bubbles. In addition, oral bowel preparation solutions with enema agents and prokinetics were used to improve bowel preparation, but no improvement was observed. Various alternative laxatives are available; however, PEG-based bowel preparation solutions are still recommended in most cases due to their stability. Discussion and Conclusion: Although a 4-L PEG solutions recommended for bowel preparation in most cases, several laxatives have been introduced to overcome its disadvantages. The laxative agent must be selected according to each patient’s specific characteristics. Moreover, the method of taking bowel preparation solutions and additional bowel preparation medications must be carefully chosen. In addition, patient education via various methods, such as using a smartphone, when taking a bowel preparation agent may help improve bowel preparation quality.

Hypermagnesaemia causing mesenteric ischaemia and small bowel infarction

We present a case of mesenteric ischaemia caused by hypermagnesaemia after ingestion of a large oral dose of magnesium citrate, which resulted in smooth muscle relaxation, hypotension and bowel infarction. The patient had a history of chronic bowel dysmotility and renal impairment. On operative exploration, the bowel was noted to have a distinct pattern of ischaemia along its antimesenteric border. Small bowel resection was performed, and the patient was left in discontinuity, with definitive repair and anastomosis performed 24 hours later. The patient's magnesium level was 8.39 mg/dL, which was treated with intermittent haemodialysis and eventually normalised over several sessions. Our patient recovered and was discharged after a month-long hospitalisation. She returned shortly after with respiratory failure and died. On review of the literature, we identified similar cases and present a pathophysiological mechanism of hypermagnesaemia causing mesenteric ischaemia, consistent between our cases and those already reported.

Hypermagnesemia in a 20-month-old healthy girl caused by the use of a laxative: a case report

Background

Hypermagnesemia can be a fatal condition and should be diagnosed early on. Most reports of hypermagnesemia have been of adults with impaired renal function. We describe the case of a pediatric patient without renal dysfunction who developed severe hypermagnesemia.

Case presentation

A healthy 20-month-old Asian girl presented to our emergency department with episodes of vomiting and a reduced level of consciousness. The neurological examination showed a symmetric decrease in muscle tone, and the deep tendon reflexes were decreased. On admission, her magnesium (Mg) level was 11.0 mg/dL after receiving magnesium oxide for 4 days because of constipation. She was immediately administered calcium gluconate infusion (3.9 mEq), and then was continuously infused with it (0.23 mEq/h) as a Mg antagonist to cardiac side effects. She was kept hydrated with 0.9% sodium chloride to maintain good urine output to excrete the Mg. The level of the serum Mg decreased to 2.4 mg/dL, enabling her to regain consciousness. During 5 years of follow-up, she was neurologically well, without the recurrence of hypermagnesemia.

Conclusions

Even in the absence of significant renal dysfunction, the prescription of a laxative containing Mg for constipation can result in severe hypermagnesemia. In addition, the symptoms of hypermagnesemia are nonspecific, and early diagnosis is difficult unless it is actively suspected.

Possibility of magnesium supplementation for supportive treatment in patients with COVID-19

Magnesium as an enzymatic activator is essential for various physiological functions such as cell cycle, metabolic regulation, muscle contraction, and vasomotor tone. A growing body of evidence supports that magnesium supplementation (mainly magnesium sulfate and magnesium oxide) prevents or treats various types of disorders or diseases related to respiratory system, reproductive system, nervous system, digestive system, and cardiovascular system as well as kidney injury, diabetes and cancer. The ongoing pandemic coronavirus disease 19 (COVID-19) characterized by respiratory tract symptoms with different degrees of important organ and tissue damages has attracted global attention. Particularly, effective drugs are still lacking in the COVID-19 therapy. In this review, we find and summarize the effectiveness of magnesium supplementation on the disorders or diseases, and provide a reference to the possibility of magnesium supplementation for supportive treatment in patients with COVID-19.

Adverse drug event of hypokalaemia-induced cardiotoxicity secondary to the use of laxatives: A systematic review of case reports

WHAT IS KNOWN AND OBJECTIVE

The imbalance in serum potassium caused by laxatives can negatively affect the cardiovascular system, leading to life-threatening consequences. Our objective was to evaluate the reported evidence of adverse events related to the cardiac system due to laxative-induced hypokalaemia from case reports.

METHODS

A systematic electronic literature search of PubMed, Embase, the Cochrane Library and Science Direct was conducted for the period 1995-2019. In these databases, search terms describing hypokalaemia and cardiotoxicity were combined with the term laxative use.

RESULTS AND DISCUSSION

Over the 23 years, 27 incidents were identified in 12 countries. There were 19 female and eight male patients, with ages ranging from 1 month to 93 years. The frequency of reported cases according to severity was the following: severe hypokalaemia 48%, moderate hypokalaemia 44.4% and mild hypokalaemia 7.4%. In 70% of patients, the effect of laxative on the heart was typical hypokalaemic electrographic changes, 7.4% showed abnormal changes in cardiac rhythm, whereas in 18.5%, the cardiotoxicity observed was a very serious kind. Two patients died due to severe cardiac effects.

WHAT IS NEW AND CONCLUSION

The laxatives-along with the involvement of some other contributing factors-caused mild-to-severe hypokalaemic cardiotoxicity. These factors were non-adherence of the patient to the recommended dosage, laxative abuse, drug-drug and drug-disease interactions, non-potassium electrolyte imbalances and the use of herbal laxatives. We recommend that laxatives and aggravating factors should be taken into account in the assessment of patients with suspected hypokalaemic cardiotoxicity.

New Ultra Low Volume Bowel Preparation and Overview of Existing Bowel Preparations

BACKGROUND

Adequate bowel cleansing is essential in achieving a good quality colonoscopy. However, one of the barriers to achieving high-quality bowel cleansing is the patient's tolerability. Different bowel preparations have been developed to improve tolerability while maintaining adequate bowel cleansing.

OBJECTIVES

We aim to explore the pros and cons of commonly used bowel preparations, particularly highlighting the new ultra-low volume bowel preparation.

METHODS

Extensive literature search was carried out on various databases to evaluate the effectiveness and side effects of different bowel cleansing agents, including findings of recent clinical trials on ultra-low bowel preparation.

RESULTS

Polyethylene glycol (PEG) has been commonly used as a bowel prep. Due to its high volume required to ingest to achieve an adequate effect, it has been combined with various adjuncts to reduce the volume to make it more tolerable. Magnesium and phosphate-based preps can achieve low volume, but they can be associated with multiple side effects, mainly electrolyte disturbances. Ultra low volume prep (NER1006) was achieved by combing PEG with ascorbic acid, and its efficacy and side effects were demonstrated in three noninferiority studies.

CONCLUSION

It is important to consider patient preferences, co-morbidities and tolerability, and efficacy and side effect profiles when choosing bowel prep for patients undergoing colonoscopy. New ultra-low bowel prep showed promising results in initial clinical trials, but further real-world post-marketing data will inform its value in clinical practice.

Severe Hypermagnesemia with Normal Renal Function Can Improve with Symptomatic Treatment

Hypermagnesemia is a rare disorder and commonly occurs in patients with renal dysfunction. Supportive therapy for hypermagnesemia consists of administration of high-volume fluids, calcium preparation, diuretics, and, in severe cases, hemodialysis. Few reports have described severe hypermagnesemia patients with normal renal function who improved without hemodialysis. A 56-year-old woman presented with a history of constipation in spite of taking constipation medicine, including MgO. She was brought to our emergency department due to vomiting and diffuse distension of the abdomen. Sudden vomiting, weakness, and lower level of consciousness occurred during examination. Her blood pressure dropped to 77/34 mmHg, and deep tendon reflexes of the limbs disappeared. Abdominal computed tomography showed bowel distension with wall edema, and biochemical testing showed serum Mg at 13.5 mg/dl. She was diagnosed with severe hypermagnesemia associated with intestinal obstruction and administered intravenous loop diuretics and calcium preparation in addition to high volumes of normal saline. As the serum Mg level steadily declined, her level of consciousness returned to usual. This case suggests that severe hypermagnesemia can occur in patients with normal renal function and constipation under MgO. Severe hypermagnesemia with normal renal function can improve with symptomatic treatment without hemodialysis.

[Medical Dispute Related to Gastrointestinal Endoscopy Complications: Prevention and Management]

Because gastrointestinal (GI) endoscopy examinations are being performed increasingly frequently, the rate of detection of cancer and of precancerous lesions has increased. Moreover, development of more advanced endoscopic technologies has expanded the indications for, and thus frequency of, therapeutic endoscopic procedures. However, the incidence of complications associated with diagnostic or therapeutic GI endoscopy has also increased. The complications associated with GI endoscopy can be ameliorated by endoscopic or conservative treatment, but caution is needed as some of the more serious complications, such as perforation, can lead to death. In this chapter, we review the possible complications of GI endoscopy and discuss methods for their prevention and treatment.

Clinical features of hypermagnesemia in patients with functional constipation taking daily magnesium oxide

Although magnesium oxide is widely used as a laxative, alterations in serum magnesium concentrations among patients taking daily magnesium oxide have not been clarified. The present retrospective, cross-sectional study investigated the risk factors for hypermagnesemia in patients taking daily oral magnesium oxide. Of 2,176 patients administered daily magnesium oxide, 193 (8.9%) underwent assays of serum magnesium concentrations and were evaluated. High serum magnesium concentration and hypermagnesemia were defined as serum magnesium concentrations ≥2.5 mg/dl and ≥3.0 mg/dl, respectively. Of the 193 patients taking daily magnesium oxide, 32 (16.6%) had high serum magnesium concentration and 10 (5.2%) had hypermagnesemia. Factors associated with hypermagnesemia included chronic kidney disease (CKD) grade 4 (p = 0.014) and magnesium oxide dosage (p = 0.009). Factors associated with high serum magnesium concentration included magnesium oxide dosage >1,000 mg/day (p = 0.004), CKD grades 4 (p = 0.000) and concomitant use of stimulant laxatives (p = 0.035). Age, however, was not associated with hypermagnesemia or high serum magnesium concentration. In conclusion, renal function and magnesium oxide dosage, but not age, were associated with hypermagnesemia and high serum magnesium concentration in patients with functional constipation taking daily magnesium oxide.

A Rare Presentation of Hypermagnesemia Associated with Acute Kidney Injury due to Hypercalcemia

A 79-year-old Japanese woman presented with consciousness disturbance, hypercalcemia, and hypermagnesemia. She had rheumatoid arthritis and osteoporosis. Three months before admission, she was treated with oral calcitriol for osteoporosis. Two months before admission, she was treated with magnesium oxide for constipation. One month before admission, she underwent articular femoral bone replacement. Two weeks postoperatively, consciousness disturbance and elevated serum calcium levels were observed, and she was transferred to our hospital. On admission, her laboratory data showed elevated serum magnesium and creatinine levels. This is a rare case of coexistent hypercalcemia and hypermagnesemia associated with consciousness disturbance and acute kidney injury.

Review article: the pharmacological causes of colon ischaemia

BACKGROUND

Colon ischaemia is the most common ischaemic disorder of the gastrointestinal system, can affect any segment of the colon, and may present with a range of symptoms. Diagnosis can be challenging due to symptom overlap with other conditions, varied aetiology, and often rapid and self-resolving course.

AIM

To review comprehensively the literature regarding the pharmacological aetiologies of colonic ischaemia to enhance the understanding of the various mechanisms of disease, presentations, distribution, and outcomes.

METHODS

A PubMed search for "colon ischaemia" and "ischaemic colitis" alone as well as in combination with various known pharmacologic causes was performed. Only the highest quality and relevant literature was included in this review. The quality of the literature for each association was rated by the authors and a consensus was made when discrepancies were encountered. Only associations that were deemed "moderate" or "strong" were included.

RESULTS

The literature considering pharmacologically associated colonic ischaemia is diverse, lacks codification and is characterised by numerous case reports and case series. Constipation-inducing drugs, digoxin, hormonal therapies, illicit drugs, immunomodulators, laxatives, and NSAIDs were strongly associated with colonic ischaemia. Antimicrobials, appetite suppressants, chemotherapies, decongestants, diuretics, ergot alkaloids, serotonin agents, statins, and vasopressor agents were moderately associated.

CONCLUSIONS

Patients presenting with abdominal pain, diarrhoea, or bloody stool need to be evaluated for the possibility of this condition and treated accordingly. Timely diagnosis is necessary to improve patient outcomes. This review aims to increase awareness among clinicians regarding the presentation of pharmacologically induced colonic ischaemia.

Severe hypermagnesemia induced by magnesium oxide ingestion: a case series

Hypermagnesemia is generally considered an exceptional iatrogenic condition usually caused by magnesium-containing cathartics. In particular, this condition often develops when magnesium-containing cathartics are administered to elderly patients with renal insufficiency or bowel movement dysfunction. Although magnesium oxide (MgO) is widely prescribed as a laxative, serum magnesium concentration has not been examined in most cases. In this report, we present the cases of four elderly patients with constipation and symptomatic hypermagnesemia caused by MgO ingestion, one of which had a lethal course. All of the patients were older than 65 years and with renal dysfunction. In addition, they had difficulties in expressing their symptoms because of cerebrovascular events or dementia. These cases suggest that hypermagnesemia caused by magnesium-containing cathartics is more likely to develop than previously recognized and that physicians should be aware that patients with chronic kidney disease and the elderly are at risk of hypermagnesemia on magnesium administration. We recommend serum magnesium monitoring for high-risk patients after initial prescription or dose increase.

Bradycardia and Hypotension from Improper Use of Aconite Root: A Case Report and Brief Review

Background: Adverse reactions associated with Chinese herbal medicines (CHMs) are usually the result of unpredictable active/toxic ingredients, inaccurate or mistaken beliefs, or poor supervision. The herb that most commonly induces severe adverse effects in Hong Kong and China is aconite root. More than 200 species of Aconitum plants are used for medicinal purposes, with aconite roots producing analgesic, anti-inflammatory, cardiotonic, and anti-tumor effects. The active components are alkaloids; these can be toxic, but CHM processing methods lower their toxicity and increase the pharmacological efficacy. However, aconite poisoning can result from inadequate decoction time or exceeding the recommended dose. Case Report: Here we report the case of a 92-year-old woman who presented with life-threatening bradycardia and hypotension. This started 1 h after she inappropriately consumed a herbal decoction containing Fuzi for mood fluctuation and health maintenance; Fuzi, an aconite root, has known cardiotoxicity. Electrocardiography showed supraventricular abnormalities, including sinus bradycardia and low-amplitude P waves. After an infusion of normal saline and inotropic agents for 25 h, the clinical manifestations subsided, her sinus rhythm returned to normal, and she was discharged. At follow-up 2 weeks later, she was in good health and had ceased taking any CHM. Conclusions: Standardized processing methods, stringent regulations, and cooperation between health professions can ensure medication safety and establish a fully-fledged operating process for these valuable drugs. We hope this report will help establish correct attitudes toward CHM and will assist Traditional Chinese Medicine practitioners to become more familiar with Aconitum plants.

The characteristics of patients with hypermagnesemia who underwent emergency hemodialysis

Aim

This study aimed to clarify the characteristics of patients who presented with severe hypermagnesemia and subsequently underwent emergency hemodialysis.

Methods

We investigated the age, gender, complications, clinical symptoms, causal drugs, electrocardiogram findings, and laboratory data of 15 patients.

Results

Magnesium oxide had been administered in all cases and 14 patients were over 65 years old. The male : female ratio was 6:9. Chief complaints included a disturbance of consciousness, hypotension, bradycardia, and respiratory failure. The median serum magnesium value before hemodialysis was 6.0 (3.7–18.6) mg/dL. The daily dosage of magnesium oxide was ≤ 2.0 g in 12 cases. The median serum creatinine value before hemodialysis was 5.39 (0.54–10.29) mg/dL. However, in two cases, the creatinine value was not elevated. Complications of acute kidney injury exacerbated the hypermagnesemia in nine cases.

Conclusions

We recommend that the serum magnesium value should be measured in older patients who are taking magnesium oxide and are showing signs and symptoms of a disturbance of consciousness, hypotension, bradycardia, and respiratory failure of an uncertain etiology, even if the serum creatinine value is not elevated or the dosage of magnesium oxide is within recommended levels.

Fatal Hypermagnesemia Due to Laxative Use

We report a case of fatal hypermagnesemia in a 53-year-old woman admitted for acute exacerbation of chronic obstructive pulmonary disease and with a history of chronic constipation treated regularly with magnesium-containing laxatives. On admission, her magnesium level was 2.0mg/dL, which rose to a peak of 10.8mg/dL despite hydration and diuresis in the presence of a normal kidney function. Continuous renal replacement therapy was promptly initiated, which reduced her serum magnesium levels, but her condition continued to deteriorate precipitously progressing to shock leading to oligoanuric renal failure, and she died 2 days later. A review of the literature shows that though rare and often unsuspected, severe hypermagnesemia frequently results in death even in individuals with normal renal function despite renal replacement therapy. In patients with constipation, retention of magnesium-based laxative in the gut apparently serves as a reservoir for continuous magnesium absorption and contributes to mortality.

The management of 'hard-to-prepare' colonoscopy patients

Effective bowel cleansing is crucial for high quality colonoscopy. A notable portion of patients still present with low quality bowel preparation prior to their colonoscopy, compromising the overall quality of their colonoscopy. Areas covered: This review focuses on the main strategies that can improve the cleansing quality with a special interest on those clinical conditions that have been associated with a poor bowel preparation quality, such as patients with chronic constipation, history of bowel resection, liver cirrhosis, diabetes mellitus and chronic kidney disease. The review provides a practical and evidence-based approach to help clinicians in the management of 'hard-to-prepare' patients. Expert commentary: In the past few years, the quality of colonoscopy has become a hot topic and bowel cleansing is a crucial part of it; however, the approach to patients with an increased risk of poor bowel preparation quality is still not always supported by high-quality evidence, since most of these patients are routinely excluded from the clinical studies. Trials focused on this subgroup of patients are recommended to provide tailored bowel preparation regimens and guarantee high-quality procedures.

Optimizing bowel preparation for colonoscopy: a guide to enhance quality of visualization

Colonoscopy is an important screening and therapeutic modality for colorectal cancer. Unlike other screening tests, colonoscopy is dependent on pre-procedure bowel preparation. If the bowel preparation is poor, significant pathology may be missed. Many factors are known to improve bowel preparation. This review will highlight those factors that may optimize the bowel preparation, including choice of bowel preparation, grading or scoring of the bowel preparation, special factors that influence preparation, and diet prior to colonoscopy that affects bowel preparation. The aim of the review is to offer suggestions and guide endoscopists on how to optimize the bowel preparation for the patients undergoing colonoscopy.

Induction of potentially lethal hypermagnesemia, ischemic colitis, and toxic megacolon by a preoperative mechanical bowel preparation: report of a case

A 67-year-old man was diagnosed with rectal cancer. The tumor invaded the subserosal layer, but it was not large, and there was no sign of obstruction. Neo-adjuvant chemotherapy reduced the size of the tumor. The patient was admitted to our hospital for surgery. For mechanical bowel preparation, he ingested 34 g of magnesium citrate (Magcorol P®), but then developed severe shock, a disturbance of consciousness, and acidemia, and he required catecholamines and mechanical ventilation. X-ray, CT, and laboratory tests revealed ischemic colitis, toxic megacolon, and hypermagnesemia (16.3 mg/dL). After 2 days of temporary hemodialysis and an enema to reduce his blood magnesium concentration, he recovered and left the intensive care unit. However, the left side of his colon had suffered ischemic damage and become irreversibly atrophied. One month later, he underwent laparoscopic abdominoperineal resection and left-side colectomy for the rectal cancer and severe ischemic colitis of the left side of the colon. Histopathology confirmed the rectal cancer with a grade 2 chemotherapeutic effect and severe ischemic colitis of the left side of the colon. Hence, the present case suggests that severe ischemic colitis, toxic megacolon, and hypermagnesemia can occur after taking a magnesium laxative without obstruction of the intestine.

Biodegradable magnesium screws and vascularized iliac grafting for displaced femoral neck fracture in young adults

Objective

Avascular necrosis of femoral head and nonunion is a major complication after the treatment of displaced femoral neck fracture in young adults.

The purpose of this study was to introduce a new technique using biodegradable magnesium screws and vascularised iliac grafting for displaced femoral neck fracture in young adults.

Methods

Totally 19 patients with displaced femoral neck fracture treated with this technique were retrospectively reviewed. The major steps of this technique included the harvesting of vascularized iliac graft, fixing of the fracture and biodegradable magnesium screws combined with vascularized iliac grafting implantation.

Results

All patients were followed for an average of 16 months (range: 8–24 months). Clinical and radiological outcomes were evaluated. In 18 cases (94.7 %), the hip union was achieved at an average duration of 4.1 months (range: 3.6-5 months). The nonunion was observed in 1 hip (5.3 %) and the revision to a hip replacement was conducted after twelve months of the operation. According to the Harris hip score (HHS) that was available for 17 hips with satisfactory union, excellent results were achieved in 14 cases (HHS ≥ 90), fair results in 3 cases (HHS: 80–90), and poor result in 1 hip (HHS < 80). No patient developed avascular necrosis of femoral head after operation.

Conclusion

Biodegradable magnesium screws and vascularized iliac grafting based on the ascending branch of lateral femoral circumflex artery for displaced femoral neck fracture in young adults can provide the satisfactory results with a low rate of complications including avascular necrosis and nonunion.

Trial registration

This prospective and randomized controlled study was registered in the Chinese Clinical Trial Registry (ChiCTR-TRC-13003238). Date of registration: 2013-3-21.

Serum magnesium concentrations in patients receiving sodium picosulfate and magnesium citrate bowel preparation: an assessment of renal function and electrocardiographic conduction

BACKGROUND

We performed a post hoc analysis of two clinical trials to assess whether sodium picosulfate and magnesium (Mg(2+)) citrate (Prepopik(®) [P/MC]), a dual-action bowel preparation for colonoscopy, has an impact on serum Mg(2+) levels and cardiac electrophysiology. Although rare, hypermagnesemia has been reported in patients consuming Mg(2+)-containing cathartics, especially patients who are elderly and have renal impairment.

METHODS

Data were analyzed from two prospective, Phase III, randomized, assessor-blinded, active-control, multicenter, pivotal studies that investigated split-dose/day-before P/MC. Serum Mg(2+) and creatinine clearance (CrCl) were measured at screening, on the day of colonoscopy, and 24-48 hours, 7 days, and 4 weeks after colonoscopy; electrocardiograms also were obtained at these time points.

RESULTS

In total, 304 patients received split-dose P/MC and 294 patients received day-before P/MC. Only 10% of the patients had serum Mg(2+) above the upper limit of normal (1.05 mmol/L) on the day of colonoscopy. There was a slight inverse correlation between CrCl and Mg(2+) levels on the day of colonoscopy; however, even at the lowest CrCl, serum Mg(2+) remained below clinically significant levels of 2.0 mmol/L. Increases in serum Mg(2+) were transient, with levels returning to baseline within 24-48 hours, regardless of renal function. No patients with elevated Mg(2+) experienced a corrected QT (QTc) interval >500 milliseconds or a QTc interval increase of ≥60 milliseconds from baseline. P/MC had no impact on PR or QRS interval.

CONCLUSION

P/MC produces little impact on serum Mg(2+) levels with no clinically significant effect on cardiac conduction in patients, including those with mild-to-moderate renal impairment.

Relationship between renal function and serum magnesium concentration in elderly outpatients treated with magnesium oxide

AIMS

We investigated the relationship between renal function and serum magnesium concentration in elderly patients treated with magnesium oxide (MgO) in an outpatient setting of an urban hospital in Japan.

METHODS

In the present study, 44 elderly outpatients (23 patients with constipation treated with daily oral MgO and 21 untreated patients in the control group) who visited Kameyama municipal medical center were enrolled. Variables were age, sex, weight, height, serum magnesium concentration, serum blood urea nitrogen level, serum creatinine level, use of other magnesium-containing supplements and symptoms associated with hypermagnesemia. We calculated the estimated glomerular filtration rate (eGFR) and classified patients based on eGFR category.

RESULTS

Compared with the control group, the MgO group showed a significantly higher concentration of serum magnesium (median 2.2 mg/dL [interquartile range 2.1-2.3] vs 2.4 mg/dL [2.2-2.6], P < 0.001). Hypermagnesemia (>2.6 mg/dL) was noted only in the MgO group. However, symptoms associated with hypermagnesemia occurred in patients from both groups, with no significant difference between groups. In the MgO group, significant difference was seen in the median serum magnesium concentration between eGFR categories (P < 0.05). The category G4 (eGFR 15-29 mL/min/1.73 m(2) ) group had the highest serum magnesium concentration in the MgO group (3.0 mg/L [2.9-3.1]).

CONCLUSIONS

Elderly patients treated with MgO have higher serum magnesium levels compared with the control group. MgO should be prescribed with caution in patients with low renal function as shown by a GFR category G3b or less (eGFR < 30 mL/min/1.73 m(2) ). Geriatr Gerontol Int 2016; 16: 600-605.

Magnesium basics

As a cofactor in numerous enzymatic reactions, magnesium fulfils various intracellular physiological functions. Thus, imbalance in magnesium status-primarily hypomagnesaemia as it is seen more often than hypermagnesaemia-might result in unwanted neuromuscular, cardiac or nervous disorders. Measuring total serum magnesium is a feasible and affordable way to monitor changes in magnesium status, although it does not necessarily reflect total body magnesium content. The following review focuses on the natural occurrence of magnesium and its physiological function. The absorption and excretion of magnesium as well as hypo- and hypermagnesaemia will be addressed.

A case report of bittern intoxication

Bittern is made from marine water after extraction of salt, and its major components include magnesium chloride, magnesium sulfate, potassium chloride, sodium chloride and magnesium bromide. For a long time, it has been used as the main ingredient of tofu coagulant and chemical weapons. A 73-year-old woman arrived to the emergency department after a suicide attempt by drinking an unknown amount bittern. She complained of dizziness, general weakness, and altered mental state (Glasgow Coma Scale (GCS) 13/15). The brain computed tomography (CT) and magnetic resonance imaging (MRI) showed no abnormality. But blood chemistry showed hypermagnesemia ([Mg(2+)] 7.8 mEq/L) and hypernatremia ([Na(+)] 149 mEq/L). Electrocardiograph showed QT prolongation of 0.482 s. Electrolyte imbalances were corrected following adequate fluid therapy and injection of calcium gluconate. The patient recovered/was subsequently discharged without any complications. Electrolyte imbalances are a common presentation following bittern poisoning. Severe side effects like respiratory depression, hypotension, arrhythmia, bradycardia, and cardiac arrest can also occur. Patients will require immediate fluid therapy and correction of electrolyte imbalances. The symptoms vary depending on the electrolyte levels. It is mandatory to closely monitor the electrolyte levels and electrocardiograph in these patients.

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

In this report, we present a pediatric case of severe symptomatic hypermagnesemia resulting from the use of magnesium oxide as a laxative in a child undergoing continuous cyclic peritoneal dialysis for end-stage renal disease. The patient showed abnormal electrocardiography (ECG) findings, such as tall T waves, a widened QRS complex, and irregular conduction, which were initially misdiagnosed as hyperkalemia; later, the correct diagnosis of hypermagnesemia was obtained. Emergent hemodialysis successfully returned the serum magnesium concentration to normal without complications. When abnormal ECG changes are detected in patients with renal failure, hypermagnesemia should be considered.

Fatal hypermagnesemia induced by preoperative colon preparation in an elderly woman: report of a case

An 85-year-old woman with rectal carcinoma was referred to our hospital for surgical treatment. She had a history of constipation treated with oral magnesium oxide. She received 34 g of magnesium citrate (Magcolol P(®)) orally for 2 days as a mechanical bowel preparation prior to the operation. Just before the operation, she suddenly developed nausea, vomiting, and cyanosis and went into cardiac arrest. Despite support by mechanical ventilation, dopamine, dobutamine, and norepinephrine, she exhibited repeated bradycardia that was nearly fatal and required temporary pacing. The following day, her laboratory tests revealed marked hypermagnesemia (14.3 mg/dL). After a hemodialysis session, she recovered dramatically and all vasopressors were withdrawn. We conclude that preoperative mechanical bowel preparation with magnesium-containing cathartics can cause fatal hypermagnesemia in elderly patients even if their renal function is normal.

[Magnesium disorders]

Extracellular content in magnesium represents about 1% of total body content, of which plasma magnesium is thus a poor reflect. Hypomagnesaemia is defined by a value lesser than 0.65mmol/L. Its incidence in hospitalized patients ranges between 10 and 15%. Identification of the physiopathology of hypomagnesaemia relies first upon concomitant measurement of plasma and urinary magnesium concentration. Daily magnesium excretion lesser than 1mmol/L or EFMg lesser than 1% sign extra renal origin, due to either low magnesium intake, low intestinal absorption of magnesium or derivation of extracellular magnesium toward bone, such as in bone reparation process after hyperparathyroidism surgery. Daily magnesium excretion higher than 2mmol/L concomitant to hypomagnesaemia indicates native or acquired renal loss of magnesium. Congenital renal and extra-renal losses of magnesium are mainly related to rare monogenic disease, and are inconstantly associated with a renal loss of sodium, potassium and calcium. Recent progress in the genetics of this rare diseases have greatly improved the knowledge about proteins involved in intestinal abortion, renal renal tubular re-absorption of magnesium and its regulations. Hypermagnesemia is a rarer metabolic disorder than hypomagnesemia (about 5% of hospitalized patients). Asymptomatic below 2mmol/L, it progressively alters neuromuscular transmission, autonomic sympathic activity and cardiac conduction, with vital risk above 7mol/L. It is due to acute magnesium input into extracellular volume most often associated with a decrease in glomerular filtration rate, limiting the high physiological ability to excrete magnesium input.

In vitro biodegradation behavior of magnesium and magnesium alloy

Magnesium has the potential to be used as degradable metallic biomaterial. For magnesium and its alloys to be used as biodegradable implant materials, their degradation rates should be consistent with the rate of healing of the affected tissue, and the release of the degradation products should be within the body's acceptable absorption levels. Conventional magnesium degrades rapidly, which is undesirable. In this study, biodegradation behaviors of high purity magnesium and commercial purity magnesium alloy AZ31 in both static and dynamic Hank's solution are systematically investigated. The in vitro test results show that magnesium purification and selective alloying are effective approaches to reduce the degradation rate of magnesium. In the static condition, the corrosion products accumulate on the materials surface as a protective layer, which results in a lower degradation rate than the dynamic condition. Anodized coating can significantly further reduce the degradation rate of magnesium. This study strongly indicates that magnesium can be used as degradable implant material as long as the degradation is controlled at a low rate. Magnesium purification, selective alloying, and anodized coating are three effective approaches to reduce the rate of degradation.

A case of cardiopulmonary arrest caused by laxatives-induced hypermagnesemia in a patient with anorexia nervosa and chronic renal failure

We report a case of laxatives induced severe hypermagnesemia complicated with cardiopulmonary arrest. A 55-year-old woman, with nephritic syndrome and anorexia nervosa, was later transported to our emergency room (ER) because of oliguria and consciousness disturbance. During transfer to the intensive care unit from the ER, cardiopulmonary arrest suddenly occurred. Cardiopulmonary resuscitation was immediately performed, and spontaneous circulation was restored after 3 min. Thereafter, administration of dopamine, norepinephrine, and epinephrine was required to maintain systolic blood pressure at 80 mmHg. Arterial blood gas analysis showed severe metabolic alkalosis, and blood biochemical tests revealed hypermagnesemia (serum magnesium concentration, 18.5 mg/dl) and renal dysfunction. Continuous infusion of diuretics followed by massive hydration and continuous hemodiafiltration (CHDF) was started. Five days after starting CHDF, magnesium concentration was almost normalized and administration of catecholamine was stopped. It was thought that progression of renal dysfunction that occurred in the patient taking a magnesium product for chronic constipation caused reduction in magnesium excretion ability, resulting in hypermagnesemia-induced cardiopulmonary arrest. To avoid a rebound phenomenon following magnesium flux from cells, continuous blood purification seems to be an effective treatment for symptomatic hypermagnesemia.

Mechanism of action and toxicities of purgatives used for colonoscopy preparation

IMPORTANCE OF THE FIELD

In developed countries, colonoscopy volume has increased dramatically over the past 15 years and is the principle method used to screen for colon cancer. Preparations used for colon cleaning have evolved over the past 30 years. Some preparations have been shown to be unsafe and are now used on a limited basis. There has been progress on limiting the volume required and on taste improvement.

AREAS COVERED IN THIS REVIEW

This review provides an account of preparations used from 1980 when PEG-based preparations became widely available, until the present day. The review highlights their mechanism of action and principle toxicities. The handling of solutes and solute-free fluid by the colon is also reviewed.

WHAT THE READER WILL GAIN

The reader will gain a perspective on the factors considered in developing colonic purgatives and the rationale for choosing selected preparations based on patient factors such as age, co-morbidities and concomitant medications.

TAKE HOME MESSAGE

Although generally safe and effective, colonic purgatives have both acute and permanent toxicities. The safest preparations utilize PEG combined with a balanced electrolyte solution. Limitations of this preparation center on the volume required and poor taste. Alternative formulations are now available; however, those using sodium phosphate have fallen out of favor due to a risk of renal toxicity.

The safety of osmotically acting cathartics in colonic cleansing

Efficient cleansing of the colon before a colonoscopy or a radiological examination is essential. The osmotically acting cathartics (those given the Anatomical Therapeutic Chemical code A06AD) currently used for this purpose comprise products based on three main substances: sodium phosphate, combinations of polyethylene glycol and electrolyte lavage solutions (PEG-ELS), and magnesium citrate. All these preparations give adequate cleansing results and have similar profiles in terms of the frequency and type of mild to moderate adverse effects. However, serious adverse events, such as severe hyperphosphatemia and irreversible kidney damage owing to acute phosphate nephropathy, have been reported after use of sodium-phosphate-based products. The aim of this Review is to provide an update on the potential safety issues related to the use of osmotically acting cathartics, especially disturbances of renal function and water and electrolyte balance. The available evidence indicates that PEG-ELS-based products are the safest option. Magnesium-citrate-based, hypertonic products should be administered with caution to elderly individuals and patients who are prone to develop disturbances in water and electrolyte balance. Sodium-phosphate-based products can occasionally cause irreversible kidney damage and should not be routinely used in bowel-cleansing procedures.

Perioperative management for a patient with hypermagnesemia-induced shock with perforative peritonitis

We present a case of hypermagnesemia accompanied by perforative peritonitis. A 79-year-old woman took magnesium citrate as part of the pretreatment on the day before a scheduled colonoscopy. She developed nausea and muscle weakness, and she was complaining of left abdominal pain. Consciousness gradually worsened and she developed shock. Intestinal obstruction was recognized on abdominal X-ray and computed tomography (CT), and peritonitis was suspected. An exploratory laparotomy was scheduled for diagnosis and treatment. In the operating room, arterial blood gas analysis showed metabolic acidosis and hypermagnesemia (Mg: 2.75 mmol/l, normal range: 0.1-1.5 mmol/l). On laparotomy, adhesion around the sigmoid colon and turbid ascites were recognized. But we could not detect the apparent region of perforation. Based on these findings and the presence of hypermagnesemia, we diagnosed that the shock was caused by peritonitis due to intestinal micro-perforation, and by hypermagnesemia due to absorption of laxative. We started to treat for metabolic acidosis, and to manage the hypermagnesemia by calcium hydrochloride administration and by continuous hemodiafiltration after the operation. On day 4 of the illness, the plasma Mg level was normalized. She was extubated on day 12, and discharged on day 84. This case with complicated clinical symptoms reaffirms the difficulty and importance of making a diagnosis quickly by collecting various data.

Case files of the medical toxicology fellowship of the California poison control system-San Francisco: calcium plus digoxin-more taboo than toxic?

A 68 year old woman with a history of diabetes mellitus presented to the emergency department after experiencing several days of nausea and vomiting. Recorded vital signs included: blood pressure 98/32 mm Hg, heart rate 69 bpm, "normal" respirations, and no fever. Her initial ECG revealed peaked T waves and regular rhythm with no visible P waves. Initial serum electrolytes were notable for a potassium level of 7.7 mmol/L, and a creatinine level of 9.6 mg/dL (849 micromol/L). She was unable to provide a list of her current medications or other medical history. There was no old chart immediately available for comparison.

Hypermagnesemia predicts mortality in elderly with congestive heart disease: relationship with laxative and antacid use

The aim of this study was to evaluate the role of magnesium levels on 3-year survival in the elderly with congestive heart failure (CHF) admitted to the Rehabilitative Cardiology Unit of S. Maugeri Foundation Scientific Institute of Telese/Campoli. All elderly patients > or = 65 years old with a diagnosis of CHF underwent clinical and instrumental examination, and their demographics, co-morbidity, and in-hospital and 3-year mortality rates were recorded. Hypomagnesemia was found in 4.8%, normomagnesemia in 67.5%, and hypermagnesemia in 27.8% of subjects. The hypomagnesemic group was excluded for numerical exiguity; the analysis was performed on a total of 199 elderly patients. Hypermagnesemia was found in 29.1% and normomagnesemia in 70.9%. At the univariate analysis no differences were found in hypermagnesemia in respect to normomagnesemia group, except for slightly higher levels of creatininemia (1.35 +/- 0.61 vs. 1.13 +/- 0.55 mg/dL, respectively; p < 0.02), greater disability (lost ADL, 2.69 +/- 1.57 vs. 2.15 +/- 1.56, respectively; p < 0.05), more mortality for CHF (32.6 vs. 48.3%; p < 0.05), and higher antacid and laxative use (82.7 vs. 24.8%, respectively; p < 0.0001). Patients with higher magnesium showed less probability to survive at a 3-year follow-up than did patients with lower levels (17.32 +/- 15.93 vs. 22.46 +/- 16.16 months; p < 0.05), and this finding remained significant in the multivariate analysis after adjusting for some confounders. Finally hypermagnesemia should also be considered in the absence of pre-existing renal failure clinical evidence because of its negative prognostic value, especially in elderly patients with CHF. The shown relationship between hypermagnesemia and laxative/antacid use should induce physicians to pay more attention to abuse of these drugs.

Severe hypermagnesemia as a result of excessive cathartic ingestion in a child without renal failure

A 14-year-old girl was referred to our hospital with lethargy and hypotension and was found to have a serum magnesium level of 14.9 mg/dL after having received an magnesium hydroxide (Magnesie Calcinee) for 7 days because of constipation. She was lethargic, her blood pressure was 70/40 mm Hg, and electrocardiogram revealed prolonged corrected QT interval and first-degree atrioventricular block. She has no renal dysfunction. Emergency hemodialysis after her condition ameliorated, her serum magnesium levels returned to normal. The present case suggests that massive oral magnesium ingestion with severe constipation and ileus may result severe hypermagnesemia without renal dysfunction.