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Serum magnesium has a normal range of 0.8-1.2 mMol/L. Magnesium homeostasis

is regulated by renal and gastrointestinal mechanisms. Hypermagnesemia is usually
iatrogenic and is frequently seen in conjunction with renal insufficiency.
I. Clinical Evaluation of Hypermagnesemia

A. Causes of Hypermagnesemia

1. Renal. Creatinine clearance <30 mL/minute.

2. Nonrenal. Excessive use of magnesium cathartics, especially with renal

failure; iatrogenic overtreatment with magnesium sulfate.

3. Less Common Causes of Mild Hypermagnesemia. Hyperparathyroidism,

Addison's disease, hypocalciuric hypercalcemia, and lithium therapy.

B. Hypermagnesemia is commonly caused by overzealous replacement of

magnesium, inadequate adjustment of Mg dosage for renal insufficiency, and

overuse of magnesium-containing cathartics.

1. Cardiovascular Manifestations of Hypermagnesemia

a. Lower levels of hypermagnesemia <10 mEq/L. Delayed

interventricular conduction, first-degree heart block, prolongation of the

Q-T interval.

b. Levels greater than 10 mEq/L. Heart block progressing to complete

heart block and asystole occurs at levels greater than 12.5 mMol/L

(>6.25 mMol/L).

2. Neuromuscular Effects

a. Hyporeflexia occurs at a Mg level >4 mEq/L (>2 mMol/L); an early sign

of magnesium toxicity is diminution of deep tendon reflexes caused by
neuromuscular blockade.
b. Respiratory depression due to respiratory muscle paralysis occurs at
levels >13 mEq/L (>6.5 mMol/L). Somnolence and coma occur at very

elevated levels.
c. Hypermagnesemia should always be considered when these symptoms
occur in patients with renal failure, in those receiving therapeutic

magnesium, and in laxative abuse.

II. Treatment of Hypermagnesemia

A. Asymptomatic, Hemodynamically Stable Patients

1. Moderate hypermagnesemia can be managed by elimination of intake and

maintenance of renal magnesium clearance.

B. Severe Hypermagnesemia

1. Furosemide 20-40 mg IV q3-4h should be given as needed. Saline diuresis

should be initiated with 0.9% saline, infused at 150 cc/h to replace urine


2. If ECG abnormalities (peaked T waves, loss of P waves, or widened QRS

complexes) or if respiratory depression is present, IV calcium gluconate

should be given as 1-3 ampules (10% sln, 1 gm per 10 mL amp), added to

saline infusate. Calcium gluconate can be infused as 15 mg/kg over a 4-

hour period.

3. Parenteral insulin and glucose can be given to shift magnesium into cells.
Dialysis is necessary for patients who have severe hypermagnesemia after

stabilization of the ECG findings. §