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HYPERMAGNESEMIA, a serum magnesium level greater than 2.0 mEq/L. This abnormality is rare in patients with normal renal function because large loads of magnesium are easily excreted by well-functioning kidneys. Clinical symptoms usually manifest only at serum levels greater than 4 mEq/L and include areflexia, lethargy, weakness, paralysis, diaphoresis, respiratory failure, hypotension, and bradycardia. In fact, hypermagnesemia should always be considered in the unconscious patient who lacks deep tendon reflexes. Conversely, the diagnosis of coma secondary to hypermagnesemia should be questioned if reflexes are present, and an alternate cause for altered mental status should be pursued. Electrocardiographic changes include prolonged PR, QRS and/or QT intervals, complete heart block, and asystole.
Severe symptomatic hypermagnesemia should be treated with 10% calcium gluconate (10-20 ml intravenously for 10 minutes) to temporarily antagonize the effects of magnesium on the myocardium. Supportive care may include mechanical ventilation for respiratory failure and a temporary pacemaker for bradyarrhythmias. Intravenous normal saline with 20 ml of 10% calcium gluconate per liter either with or without intravenous furosemide (Lasix) can be given at a rate of 150-200 ml/ hour to patients with normal renal function to induce diuresis and increase magnesium excretion. Hemodialysis will be required in symptomatic patients with renal failure or patients with life-threatening symptoms. Intravenous glucose and insulin can be used to temporarily decrease serum magnesium levels by driving magnesium intracellularly.