Iatrogenic magnesium toxicity following intravenous infusion of magnesium sulfate: risks and strategies for prevention

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...

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Bibliographic Details
Published in:BMJ case reports 2015-07, Vol.2015, p.bcr2015209499
Main Authors: Cavell, Gillian F, Bryant, Catherine, Jheeta, Seetal
Format: Article
Language:English
Subjects:
Aged
Biochemistry
Calcium Channel Blockers - administration & dosage
Calcium Channel Blockers - adverse effects
Colonic Neoplasms - therapy
Creatinine
Humans
Hypokalemia
Iatrogenesis
Iatrogenic Disease - prevention & control
Infusions, Intravenous
Learning from Errors
Magnesium - administration & dosage
Magnesium - adverse effects
Magnesium - blood
Magnesium Deficiency - drug therapy
Magnesium Sulfate - administration & dosage
Magnesium Sulfate - adverse effects
Male
Medication Errors - adverse effects
Medication Errors - prevention & control
Neuromuscular Diseases - chemically induced
Obstetrics
Pharmacists
Potassium
Sodium
Toxicity
United Kingdom
White
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Summary: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.
ISSN:1757-790X
1757-790X
DOI:10.1136/bcr-2015-209499