title: Iatrogenic magnesium toxicity following intravenous infusion of magnesium sulfate: risks and strategies for prevention.
abstract: A 65-year-old man being treated with radiotherapy and chemotherapy for recurrent colonic adenocarcinoma was admitted for management of hypokalaemia and hypomagnesaemia secondary to diarrhoea. He was treated with intravenous infusions of potassium chloride and magnesium sulfate. Following an infusion of magnesium sulfate, he experienced a sudden neurological deterioration. A CT of the head revealed no haemorrhage or evidence of acute ischaemic injury. Results of serum biochemistry later that day revealed an elevated magnesium level. Iatrogenic magnesium toxicity was suspected. Further discussions between the pharmacist and ward staff confirmed that a medication error had been made in the preparation of the infusion resulting in an overdose of intravenous magnesium.
authors.affiliation: King's College Hospital, London, UK.
authors.forename: Gillian F
authors.initials: GF
authors.lastname: Cavell
authors.affiliation: Department of Clinical Gerontology, King's College Hospital NHS Foundation Trust, London, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Bryant
authors.affiliation: Imperial College Healthcare NHS Trust, London, UK.
authors.forename: Seetal
authors.initials: S
authors.lastname: Jheeta
mesh_terms: D000368:Aged; D002121:Calcium Channel Blockers / Q000008:administration & dosage / Q000009:adverse effects*; D003110:Colonic Neoplasms / Q000628:therapy; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control; D007262:Infusions, Intravenous; D008274:Magnesium / Q000008:administration & dosage / Q000009:adverse effects / Q000097:blood*; D008275:Magnesium Deficiency / Q000188:drug therapy*; D008278:Magnesium Sulfate / Q000008:administration & dosage / Q000009:adverse effects*; D008297:Male; D008508:Medication Errors / Q000009:adverse effects* / Q000517:prevention & control; D009468:Neuromuscular Diseases / Q000139:chemically induced*
chemical_list: D002121:Calcium Channel Blockers; D008278:Magnesium Sulfate; D008274:Magnesium