COMMONLY USED MAGNESIUM SULFATE UNCOMMONLY CAUSING PULMONARY EDEMA

ABSTRACT

SESSION TITLE Drug-Induced Critical Care SESSION TYPE Rapid Fire Case Reports PRESENTED ON 10/19/2022 1245 pm - 145 pm INTRODUCTION: Intravenous magnesium sulfate (MgSo4) is commonly used for inpatient magnesium repletion. However, it is infrequently shown to be associated with the development of pulmonary edema. We present a case of acute hypoxic respiratory failure due to pulmonary edema after starting magnesium infusion in a patient recovering from COVID-19. CASE PRESENTATION 60 year old female with a history of metastatic breast cancer presented with hypoxic respiratory failure due to COVID-19. CT angiogram of her chest showed diffuse bilateral ground-glass opacities with no evidence of pulmonary embolism. She had prolonged weaning from high flow nasal cannula and was treated with antibiotics, remedesivir, and dexamethasone. Following treatment, her inflammatory markers significantly improved. On day thirty, she was on 25 L at 45% FiO2 on high flow nasal cannula. Her magnesium level was low at 1.5 mg/dl, and 2 grams of intravenous MgSo4 was given for replacement. A few minutes after starting the infusion, the patient complained of metallic taste, severe shortness of breath, and tachypnea with a drop in oxygen saturation to 67%, which improved with increasing oxygen. CXR showed worsening perihilar infiltrates compared to prior, suggesting acute pulmonary edema. An echocardiogram showed normal function without evidence of structural abnormalities. Thyroid function was normal. She did not receive any blood products or opioids prior to this event. She responded very well to diuresis, was weaned to 5L nasal cannula in three days, and was eventually discharged on 2L supplemental oxygen. DISCUSSION: Pulmonary edema is due to the movement of excess fluid into the alveoli. It can be due to cardiogenic and noncardiogenic causes. Noncardiogenic pulmonary edema is due to a rise in transcapillary filtration, causing an increase in capillary permeability due to several factors, most importantly direct endothelial damage due to inflammation. Mechanisms for MgSo4 induced pulmonary edema are unknown, but theories include direct capillary damage or transient cardiac depression. It is seen in studies to be an independent risk factor for the development of pulmonary edema in pregnancy. Higher risk is associated with faster MgSo4 infusion, less concentrated MgSo4, and infection[1]. She was on abemaciclib for breast cancer before her admission, known to cause pneumonitis but was thought unlikely to cause her acute decompensation. The lack of other etiologies explaining sudden respiratory failure, her rapid improvement on stopping magnesium, and her response to diuretics supported our diagnosis. CONCLUSIONS: Treatment of noncardiogenic pulmonary edema involves addressing the underlying cause of the event and is mainly supportive. Given how commonly Mgso4 is used for repletion in the inpatient setting, MgSo4 induced pulmonary edema should be in the differential for acute hypoxic respiratory failure and promptly addressed. Reference #1 Samol JM, Lambers DS. Magnesium sulfate tocolysis and pulmonary edema the drug or the vehicle? Am J Obstet Gynecol. 2005 May;192(5)1430-2. doi 10.1016/j.ajog.2005.02.093. PMID 15902128. DISCLOSURES No relevant relationships by Nasir Alhamdan No relevant relationships by Harshitha Mergey Devender No relevant relationships by Abira Usman No relevant relationships by Vishruth Vyata No relevant relationships by Harika Yadav