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Chest Oct 2022Asthma exacerbations can be life-threatening, with 25,000 to 50,000 such patients per year requiring admission to an ICU in the United States. Appropriate triage of... (Review)
Review
Asthma exacerbations can be life-threatening, with 25,000 to 50,000 such patients per year requiring admission to an ICU in the United States. Appropriate triage of life-threatening asthma is dependent on both static assessment of airway function and dynamic assessment of response to therapy. Treatment strategies focus on achieving effective bronchodilation with inhaled β-agonists, muscarinic antagonists, and magnesium sulphate while reducing inflammation with systemic corticosteroids. Correction of hypoxemia and hypercapnia, a key in managing life-threatening asthma, occasionally requires the incorporation of noninvasive mechanical ventilation to decrease the work of breathing. Endotracheal intubation and mechanical ventilation should not be delayed if clinical improvement is not achieved with conservative therapies. However, mechanical ventilation in these patients often requires controlled hypoventilation, adequate sedation, and occasional use of muscle relaxation to avoid dynamic hyperinflation, which can result in barotrauma or volutrauma. Sedation with ketamine or propofol is preferred because of their potential bronchodilation properties. In this review, we outline strategies for the assessment and management of patients with acute life-threatening asthma focusing on those requiring admission to the ICU.
Topics: Adrenal Cortex Hormones; Asthma; Humans; Ketamine; Magnesium Sulfate; Muscarinic Antagonists; Propofol; Respiration, Artificial; Status Asthmaticus
PubMed: 35218742
DOI: 10.1016/j.chest.2022.02.029 -
JAMA Aug 2023Intravenous magnesium sulfate administered to pregnant individuals before birth at less than 30 weeks' gestation reduces the risk of death and cerebral palsy in their... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Intravenous magnesium sulfate administered to pregnant individuals before birth at less than 30 weeks' gestation reduces the risk of death and cerebral palsy in their children. The effects at later gestational ages are unclear.
OBJECTIVE
To determine whether administration of magnesium sulfate at 30 to 34 weeks' gestation reduces death or cerebral palsy at 2 years.
DESIGN, SETTING, AND PARTICIPANTS
This randomized clinical trial enrolled pregnant individuals expected to deliver at 30 to 34 weeks' gestation and was conducted at 24 Australian and New Zealand hospitals between January 2012 and April 2018.
INTERVENTION
Intravenous magnesium sulfate (4 g) was compared with placebo.
MAIN OUTCOMES AND MEASURES
The primary outcome was death (stillbirth, death of a live-born infant before hospital discharge, or death after hospital discharge before 2 years' corrected age) or cerebral palsy (loss of motor function and abnormalities of muscle tone and power assessed by a pediatrician) at 2 years' corrected age. There were 36 secondary outcomes that assessed the health of the pregnant individual, infant, and child.
RESULTS
Of the 1433 pregnant individuals enrolled (mean age, 30.6 [SD, 6.6] years; 46 [3.2%] self-identified as Aboriginal or Torres Strait Islander, 237 [16.5%] as Asian, 82 [5.7%] as Māori, 61 [4.3%] as Pacific, and 966 [67.4%] as White) and their 1679 infants, 1365 (81%) offspring (691 in the magnesium group and 674 in the placebo group) were included in the primary outcome analysis. Death or cerebral palsy at 2 years' corrected age was not significantly different between the magnesium and placebo groups (3.3% [23 of 691 children] vs 2.7% [18 of 674 children], respectively; risk difference, 0.61% [95% CI, -1.27% to 2.50%]; adjusted relative risk [RR], 1.19 [95% CI, 0.65 to 2.18]). Components of the primary outcome did not differ between groups. Neonates in the magnesium group were less likely to have respiratory distress syndrome vs the placebo group (34% [294 of 858] vs 41% [334 of 821], respectively; adjusted RR, 0.85 [95% CI, 0.76 to 0.95]) and chronic lung disease (5.6% [48 of 858] vs 8.2% [67 of 821]; adjusted RR, 0.69 [95% CI, 0.48 to 0.99]) during the birth hospitalization. No serious adverse events occurred; however, adverse events were more likely in pregnant individuals who received magnesium vs placebo (77% [531 of 690] vs 20% [136 of 667], respectively; adjusted RR, 3.76 [95% CI, 3.22 to 4.39]). Fewer pregnant individuals in the magnesium group had a cesarean delivery vs the placebo group (56% [406 of 729] vs 61% [427 of 704], respectively; adjusted RR, 0.91 [95% CI, 0.84 to 0.99]), although more in the magnesium group had a major postpartum hemorrhage (3.4% [25 of 729] vs 1.7% [12 of 704] in the placebo group; adjusted RR, 1.98 [95% CI, 1.01 to 3.91]).
CONCLUSIONS AND RELEVANCE
Administration of intravenous magnesium sulfate prior to preterm birth at 30 to 34 weeks' gestation did not improve child survival free of cerebral palsy at 2 years, although the study had limited power to detect small between-group differences.
TRIAL REGISTRATION
anzctr.org.au Identifier: ACTRN12611000491965.
Topics: Adult; Female; Humans; Infant; Infant, Newborn; Pregnancy; Australia; Cerebral Palsy; Gestational Age; Infant Mortality; Magnesium Sulfate; Maori People; Premature Birth; Prenatal Care; Pregnancy Outcome; Administration, Intravenous; New Zealand; Child, Preschool; Young Adult; Pacific Island People; Asian; Australian Aboriginal and Torres Strait Islander Peoples; White
PubMed: 37581672
DOI: 10.1001/jama.2023.12357 -
Obstetrics and Gynecology Clinics of... Dec 2020Periviable deliveries (less than 26 weeks) are a small percentage of deliveries but account for a disproportionately high number of long-term morbidities. Few studies... (Review)
Review
Periviable deliveries (less than 26 weeks) are a small percentage of deliveries but account for a disproportionately high number of long-term morbidities. Few studies describe interventions and outcomes for periviable preterm premature rupture of membranes (PPROM). The available reports may include only those neonates who received resuscitation, making interpretation and application difficult. Counseling should consider the impact of oligohydramnios on fetal lung development. This article discusses standard and experimental interventions that may offer neonatal benefit. Antenatal corticosteroids, antibiotics, and magnesium sulfate may improve outcomes but data to support an improvement in outcome are limited. Studies specifically evaluating these interventions are needed.
Topics: Adrenal Cortex Hormones; Amniotic Fluid; Anti-Bacterial Agents; Bronchopulmonary Dysplasia; Cerclage, Cervical; Chorioamnionitis; Female; Fetal Membranes, Premature Rupture; Fetal Viability; Gestational Age; Humans; Infant, Extremely Premature; Infant, Newborn; Infant, Premature, Diseases; Magnesium Sulfate; Pregnancy; Pregnancy Outcome; Premature Birth
PubMed: 33121650
DOI: 10.1016/j.ogc.2020.08.007 -
Postgraduate Medicine Apr 2022Pain is one of the most complex and unpleasant sensory and emotional human experiences. Pain relief continues to be a major medical challenge. The application of... (Review)
Review
Pain is one of the most complex and unpleasant sensory and emotional human experiences. Pain relief continues to be a major medical challenge. The application of systemic opioid and regional analgesia techniques has facilitated a decrease in the occurrence and gravity of pain. Magnesium has an evolving role in pain management. Magnesium sulfate (MgSO4), the pharmacological form of magnesium, is a physiological voltage-dependent blocker of -methyl-D-aspartate (NMDA)-coupled channels. In terms of its antinociceptive role, magnesium blocks calcium influx, which inhibits central sensitization and decreases preexisting pain hypersensitivity. These properties have encouraged the research of magnesium as an adjuvant agent for intra- and post-operative analgesia. Moreover, the mentioned magnesium impacts are also detected in patients with neuropathic pain. Intravenous magnesium sulfate, followed by a balanced analgesia, decreases opioid consumption. This review has focussed on the existing evidence concerning the role of magnesium sulfate in pain management in situations including neuropathic pain, postherpetic neuralgia, trigeminal neuralgia, migraine, and post-operative pain. Additional studies are required to improve the use of magnesium sulfate for pain to increase the quality of life of patients.
Topics: Analgesics; Analgesics, Opioid; Humans; Magnesium; Magnesium Sulfate; Neuralgia; Pain, Postoperative; Quality of Life
PubMed: 35086408
DOI: 10.1080/00325481.2022.2035092 -
Obstetrics and Gynecology Clinics of... Mar 2023Magnesium sulfate is one of the most commonly used medications in obstetrics, most notably for the prevention of eclamptic seizures and fetal neuroprotection of the... (Review)
Review
Magnesium sulfate is one of the most commonly used medications in obstetrics, most notably for the prevention of eclamptic seizures and fetal neuroprotection of the extremely preterm neonate. Pharmacokinetic and pharmacodynamic studies have demonstrated a variety of IV and IM regimens are effective for these indications. Existing models and data can be used to tailor treatment regimens to increase coverage in poor resource areas, maximize efficacy and minimize toxicity for patients of different weights and renal function.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Magnesium Sulfate; Pre-Eclampsia; Neuroprotection; Developing Countries; Prenatal Care
PubMed: 36822712
DOI: 10.1016/j.ogc.2022.10.003 -
The Cochrane Database of Systematic... May 2022Chronic obstructive pulmonary disease (COPD) is a chronic and progressive disease, often punctuated by recurrent flare-ups or exacerbations. Magnesium sulfate, having a... (Review)
Review
BACKGROUND
Chronic obstructive pulmonary disease (COPD) is a chronic and progressive disease, often punctuated by recurrent flare-ups or exacerbations. Magnesium sulfate, having a bronchodilatory effect, may have a potential role as an adjunct treatment in COPD exacerbations. However, comprehensive evidence of its effects is required to facilitate clinical decision-making.
OBJECTIVES
To assess the effects of magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease in adults.
SEARCH METHODS
We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) trials portal, EU Clinical Trials Register and Iranian Registry of Clinical Trials. We also searched the proceedings of major respiratory conferences and reference lists of included studies up to 2 August 2021.
SELECTION CRITERIA
We included single- or double-blind parallel-group randomised controlled trials (RCTs) assessing magnesium sulfate in adults with COPD exacerbations. We excluded cross-over trials.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias. The primary outcomes were: hospital admissions (from the emergency room); need for non-invasive ventilation (NIV), assisted ventilation or admission to intensive-care unit (ICU); and serious adverse events. Secondary outcomes were: length of hospital stay, mortality, adverse events, dyspnoea score, lung function and blood gas measurements. We assessed confidence in the evidence using GRADE methodology. For missing data, we contacted the study investigators.
MAIN RESULTS
We identified 11 RCTs (10 double-blind and 1 single-blind) with a total 762 participants. The mean age of participants ranged from 62 to 76 years. Trials were single- or two-centre trials conducted in Iran, New Zealand, Nepal, Turkey, the UK, Tunisia and the USA between 2004 and 2018. We judged studies to be at low or unclear risk of bias for most of the domains. Three studies were at high risk for blinding and other biases. Intravenous magnesium sulfate versus placebo Seven studies (24 to 77 participants) were included. Fewer people may require hospital admission with magnesium infusion compared to placebo (odds ratio (OR) 0.45, 95% CI 0.23 to 0.88; number needed to treat for an additional beneficial outcome (NNTB) = 7; 3 studies, 170 participants; low-certainty evidence). Intravenous magnesium may result in little to no difference in the requirement for non-invasive ventilation (OR 0.74, 95% CI 0.31 to 1.75; very low-certainty evidence). There were no reported cases of endotracheal intubation (2 studies, 107 participants) or serious adverse events (1 study, 77 participants) in either group. Included studies did not report intensive care unit (ICU) admission or deaths. Magnesium infusion may reduce the length of hospital stay by a mean difference (MD) of 2.7 days (95% CI 4.73 days to 0.66 days; 2 studies, 54 participants; low-certainty evidence) and improve dyspnoea score by a standardised mean difference of -1.40 (95% CI -1.83 to -0.96; 2 studies, 101 participants; low-certainty evidence). We were uncertain about the effect of magnesium infusion on improving lung function or oxygen saturation. For all adverse events, the Peto OR was 0.14 (95% CI 0.02 to 1.00; 102 participants); however, the event rate was too low to reach a robust conclusion. Nebulised magnesium sulfate versus placebo Three studies (20 to 172 participants) were included. Magnesium inhalation may have little to no impact on hospital admission (OR 0.77, 95% CI 0.21 to 2.82; very low-certainty evidence) or need for ventilatory support (NIV or mechanical ventilation) (OR 0.33, 95% CI 0.01 to 8.20; very low-certainty evidence). It may result in fewer ICU admissions compared to placebo (OR 0.39, 95% CI 0.15 to 1.00; very low-certainty evidence) and improvement in dyspnoea (MD -14.37, 95% CI -26.00 to -2.74; 1 study, 20 participants; very low-certainty evidence). There were no serious adverse events reported in either group. There was one reported death in the placebo arm in one trial, but the number of participants was too small for a conclusion. There was limited evidence about the effect of magnesium inhalation on length of hospital stay, lung function outcomes or oxygen saturation. Included studies did not report adverse events. Magnesium sulfate versus ipratropium bromide A single study with 124 participants assessed nebulised magnesium sulfate plus intravenous magnesium infusion versus nebulised ipratropium plus intravenous normal saline. There was little to no difference between these groups in terms of hospital admission (OR 1.62, 95% CI 0.78 to 3.37), endotracheal intubation (OR 1.69, 95% CI 0.61 to 4.71) and length of hospital stay (MD 1.10 days, 95% CI -0.22 to 2.42), all with very low-certainty evidence. There were no data available for non-invasive ventilation, ICU admission and serious adverse events. Adverse events were not reported. AUTHORS' CONCLUSIONS: Intravenous magnesium sulfate may be associated with fewer hospital admissions, reduced length of hospital stay and improved dyspnoea scores compared to placebo. There is no evidence of a difference between magnesium infusion and placebo for NIV, lung function, oxygen saturation or adverse events. We found no evidence for ICU admission, endotracheal intubation, serious adverse events or mortality. For nebulised magnesium sulfate, we are unable to draw conclusions about its effects in COPD exacerbations for most of the outcomes. Studies reported possibly lower ICU admissions and a lesser degree of dyspnoea with magnesium inhalation compared to placebo; however, larger studies are required to yield a more precise estimate for these outcomes. Similarly, we could not identify any robust evidence for magnesium sulfate compared to ipratropium bromide. Future well-designed multicentre trials with larger samples are required, including subgroups according to severity of exacerbations and COPD phenotypes.
Topics: Disease Progression; Dyspnea; Humans; Ipratropium; Magnesium; Magnesium Sulfate; Pulmonary Disease, Chronic Obstructive; Randomized Controlled Trials as Topic
PubMed: 35616126
DOI: 10.1002/14651858.CD013506.pub2 -
The Journal of Maternal-fetal &... Mar 2021Prevention of neurologic disability associated with preterm birth is one of the major challenges in current perinatal medicine. Magnesium sulfate (MgSO), the focus of... (Review)
Review
Prevention of neurologic disability associated with preterm birth is one of the major challenges in current perinatal medicine. Magnesium sulfate (MgSO), the focus of this review has been proposed as major step forward for that matter. MgSO is easily accessible, cheap, and has been proposed as a mandatory part of the management of inevitable preterm birth. The results of the various RCT's on the use of MgSO for neuroprotection has been the subject of many systematic reviews, other studies focused on dosing schedules, side effects and only a few focused on exploring magnesium's mechanism of action. Meanwhile, many guidelines worldwide have plugged MgSO as an essential ingredient of daily best practice when managing inevitable preterm birth because it has been shown to reduce the risk of severe neurologic deficit, in particular, cerebral palsy in appropriately selected patients. The more premature, the greater benefit associated with the use of antenatal MgSO. The dose of 4 g given intravenously 15 min continued by 1 g/h until maximum 24 h and minimum for 4 h is the standard regiment proposed in most guidelines. It should be noted, however, that a recent study found that a total dose of 64 g was associated with the maximum protective effect. Only the protocol used by the largest RCT, the BEAM trial, with a loading dose of 6 g initially followed by a 2-g/h maintenance dose, if continued for 24 h would give a total dose over 50 g. Other studies report on an increased risk of neonatal death with these high doses. Several studies expressed concerns about the risk of serious side effects for both mother and neonate. The results from the systematic review showed that the most commonly used dosage, 4 g bolus continued by 1 g/h maintenance, did not increase neonatal mortality and other suspected neonatal complication such as neonatal asphyxia, spontaneous intestinal perforation, necrotizing enterocolitis, and feeding intolerance. Giving a single bolus injection of 4 g MgSO4 for stimulating BDNF production in highly "suspicious" preterm labor, and 4 g again when preterm birth become inevitable may be best from a safety perspective and also appears to have a stronger rationale.
Topics: Female; Humans; Infant, Newborn; Magnesium Sulfate; Neuroprotection; Neuroprotective Agents; Pregnancy; Premature Birth; Prenatal Care
PubMed: 31092073
DOI: 10.1080/14767058.2019.1619688 -
Journal of the American Heart... Mar 2022Background Magnesium supplements may have beneficial effects on arterial stiffness. Yet, to our knowledge, no head-to-head comparison between various magnesium... (Randomized Controlled Trial)
Randomized Controlled Trial
Effects of Magnesium Citrate, Magnesium Oxide, and Magnesium Sulfate Supplementation on Arterial Stiffness: A Randomized, Double-Blind, Placebo-Controlled Intervention Trial.
Background Magnesium supplements may have beneficial effects on arterial stiffness. Yet, to our knowledge, no head-to-head comparison between various magnesium formulations in terms of effects on arterial stiffness has been performed. We assessed the effects of magnesium citrate supplementation on arterial stiffness and blood pressure and explored whether other formulations of magnesium have similar effects. Methods and Results In this randomized trial, subjects who were overweight and slightly obese received either magnesium citrate, magnesium oxide, magnesium sulfate, or placebo for 24 weeks. The total daily dose of magnesium was 450 mg/d. The primary outcome was carotid-to-femoral pulse wave velocity, which is the gold standard method for measuring arterial stiffness. Secondary outcomes included blood pressure and plasma and urine magnesium. Overall, 164 participants (mean±SD age, 63.2±6.8 years; 104 [63.4%] women) were included. In the intention-to-treat analysis, neither magnesium citrate nor the other formulations had an effect on carotid-to-femoral pulse wave velocity or blood pressure at 24 weeks compared with placebo. Magnesium citrate increased plasma (+0.04 mmol/L; 95% CI, +0.02 to +0.06 mmol/L) and urine magnesium (+3.12 mmol/24 h; 95% CI, +2.23 to +4.01 mmol/24 h) compared with placebo. Effects on plasma magnesium were similar among the magnesium supplementation groups, but magnesium citrate led to a more pronounced increase in 24-hour urinary magnesium excretion than magnesium oxide or magnesium sulfate. One serious adverse event was reported, which was considered unrelated to the study treatment. Conclusions Oral magnesium citrate supplementation for 24 weeks did not significantly change arterial stiffness or blood pressure. Magnesium oxide and magnesium sulfate had similar nonsignificant effects. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03632590.
Topics: Aged; Blood Pressure; Citric Acid; Dietary Supplements; Double-Blind Method; Female; Humans; Magnesium; Magnesium Oxide; Magnesium Sulfate; Middle Aged; Organometallic Compounds; Pulse Wave Analysis; Sulfates; Vascular Stiffness
PubMed: 35253448
DOI: 10.1161/JAHA.121.021783 -
British Journal of Anaesthesia Nov 2023Trials have demonstrated lower rates of acute kidney injury in critically ill patients receiving magnesium supplementation, but they have yielded conflicting results...
BACKGROUND
Trials have demonstrated lower rates of acute kidney injury in critically ill patients receiving magnesium supplementation, but they have yielded conflicting results regarding mortality.
METHODS
This is a retrospective cohort study based on the MIMIC-IV (Medical Information Mart in Intensive Care-IV) database. Adult critically ill patients with sepsis were included in the analysis. The exposure was magnesium sulfate use during ICU stay. The primary outcome was 28-day all-cause mortality. Propensity score matching (PSM) was conducted at a 1:1 ratio. Multivariable analyses were used to adjust for confounders.
RESULTS
The pre-matched and propensity score-matched cohorts included 10 999 and 6052 patients, respectively. In the PSM analysis, 28-day all-cause mortality rate was 20.2% (611/3026) in the magnesium sulfate use group and 25.0% (757/3026) in the no use group. Magnesium sulfate use was associated with lower 28-day all-cause mortality (hazard ratio [HR], 0.70; 95% CI, 0.61-0.79; P<0.001). Lower mortality was observed regardless of baseline serum magnesium status: for hypomagnesaemia, HR, 0.64; 95% confidence interval (CI), 0.45-0.93; P=0.020; for normomagnesaemia, HR, 0.70; 95% CI, 0.61-0.80; P<0.001. Magnesium sulfate use was also associated with lower ICU mortality (odds ratio [OR], 0.52; 95% CI, 0.42-0.64; P<0.001), lower in-hospital mortality (OR, 0.65; 95% CI, 0.55-0.77; P<0.001), and renal replacement therapy (OR, 0.67; 95% CI, 0.52-0.87; P=0.002). A sensitivity analysis using the entire cohort also demonstrated lower 28-day all-cause mortality (HR, 0.62; 95% CI, 0.56-0.69; P<0.001).
CONCLUSIONS
Magnesium sulfate use was associated with lower mortality in critically ill patients with sepsis. Prospective studies are needed to verify this finding.
Topics: Adult; Humans; Retrospective Studies; Magnesium Sulfate; Cohort Studies; Magnesium; Critical Illness; Propensity Score; Sepsis; Intensive Care Units
PubMed: 37684164
DOI: 10.1016/j.bja.2023.08.005 -
European Journal of Emergency Medicine... Aug 2022Atrial fibrillation with rapid ventricular response (Afib/RVR) is a frequent reason for emergency department (ED) visits and can be treated with a variety of... (Meta-Analysis)
Meta-Analysis
Atrial fibrillation with rapid ventricular response (Afib/RVR) is a frequent reason for emergency department (ED) visits and can be treated with a variety of pharmacological agents. Magnesium sulfate has been used to prevent and treat postoperative Afib/RVR. We performed a systematic review and meta-analysis to assess the effectiveness of magnesium for treatment of Afib/RVR in the ED. PubMed and Scopus databases were searched up to June 2021 to identify any relevant randomized trials or observational studies. We used Cochrane's Risk-of-Bias tools to assess study qualities and random-effects meta-analysis for the difference of heart rate (HR) before and after treatment. Our search identified 395 studies; after reviewing 11 full texts, we included five randomized trials in our analysis. There were 815 patients with Afib/RVR; 487 patients (60%) received magnesium treatment, whereas 328 (40%) patients received control treatment. Magnesium treatment was associated with significant reduction in HR [standardized mean difference (SMD), 0.34; 95% CI, 0.21-0.47; P < 0.001; I2 = 4%), but not associated with higher rates of sinus conversion (OR, 1.46; 95% CI, 0.726-2.94; P = 0.29), nor higher rates of hypotension and bradycardia (OR, 2.2; 95% CI, 0.62-8.09; P = 0.22). Meta-regressions demonstrated that higher maintenance dose (corr. coeff, 0.17; P = 0.01) was positively correlated with HR reductions, respectively. We observed that magnesium infusion can be an effective rate control treatment for patients who presented to the ED with Afib/RVR. Further studies with more standardized forms of control and magnesium dosages are necessary to assess the benefit/risk ratio of magnesium treatment, besides to confirm our observations.
Topics: Atrial Fibrillation; Emergency Service, Hospital; Heart Rate; Humans; Magnesium; Magnesium Sulfate
PubMed: 35503562
DOI: 10.1097/MEJ.0000000000000941