The importance of monitoring the level of ionized magnesium fraction in the blood in critically ill patients
Keywords:
chronic Mg2 deficiency, critically ill patients, ionized Mg2 fraction, measuring Mg2 concentration
Abstract
Background: Critical illnesses imply dysfunctions of vital organs with high risk of imminent death. Magnesium is a bioessential mineral with multiple physiological effects relevant for vital body functions. It stabilizes excitable membranes contributing to proper neuromuscular, cardiovascular and respiratory functions. Ionized Mg2+ (iMg2+) is free bioactive form of Mg2+ in body fluids. Disorders of Mg2+ status in critically ill and injured patients are often overlooked. Chronic Mg2+ deficiency is a condition of growing incidence in the general population. It is a significant factor in overall morbidity and mortality of the critically ill. Methods: Electronic search was conducted across PubMed library database without time restrictions (up to November 8, 2024), using keywords »ionized magnesium« AND »critical care patients« to identify studies investigating the value of measuring blood concentration of ionized Mg2+ fraction in patients with critical health conditions. Selection criteria included only studies on human, and excluded studies on veterinary population. Results: Since Mg2+ is predominantly an intracellular cation, it is dificult to determine Mg2+ deficiency in the body. Its early stages refer to a clinically unmanifested tissue Mg2+ deficit in the presence of normal ionized and total magnesaemia. Disconcordance between total Mg2+ and iMg2+ blood levels is frequently present in critically ill patients. Concentration of iMg2+ fraction is a more specific marker of general Mg2+ status than total Mg2+. Appropriate electrolyte analyser iMg2+ assay is needed to adequately and promptly determine Mg2+ status, and estimate the requirement for Mg2+ recompense in the case of deficiency. Conclusions: Abnormalities of Mg2+ levels are prevalent in critical patients. Their severity can impose vital threat. Monitoring iMg2+ level to assess Mg2+ status helps diagnose and correct Mg2+ disbalances to provide better patient outcome.
References
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18. Johansson M, Whiss PA. Weak relationship between ionized and total magnesium in serum of patients requiring magnesium status. Biol Trace Elem Res 2007; 115(1): 13–21.
19. Dacey MJ. Hypomagnesemic disorders. Crit Care Clin 2001; 17(1): 155–73.
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22. Wilkes NJ, Mallett SV, Peachey T, Di Salvo C, Walesby R. Correction of ionized plasma magnesium during cardiopulmonary bypass reduces the risk of postoperative cardiac arrhythmia. Anesth Analg 2002; 95(4): 828–34.
23. Xue W, You J, Su Y, Wang Q. The Effect of Magnesium Deficiency on Neurological Disorders: A Narrative Review Article. Iran J Public Health 2019; 48(3): 379–87.
24. Lozada-Martinez ID, Padilla-Durán TJ, González-Monterroza JJ, Aguilar-Espinosa DA, Molina-Perea KN, Camargo-Martinez W. et al. Basic considerations on magnesium in the management of neurocritical patients. Journal of neurocritical care 2021; 14(2): 78–87.
25. Broman M, Hansson F, Klarin B. Analysis of hypo- and hypermagnesemia in an intensive care unit cohort. Acta Anaesthesiol Scand 2018; 62(5): 648–57.
26. Lee JW. Fluid and electrolyte disturbances in critically ill patients. Electrolyte Blood Press 2010; 8(2): 72–81.
27. Curran J, Ross-White A, Sibley S. Magnesium prophylaxis of new-onset atrial fibrillation: A systematic review and meta-analysis. PLoS One 2023; 18(10): e0292974.
28. Meerman M, Buijser M, van den Berg L, van den Heuvel AM, Hoohenkerk G, van Driel V. et al. Magnesium sulphate to prevent perioperative atrial fibrillation in cardiac surgery: a randomized clinical trial: A protocol description of the PeriOperative Magnesium Infusion to Prevent Atrial fibrillation Evaluated (POMPAE) trial. Trials 2024; 25(1): 540.
29. Hutten TJA, Sikma MA, Stokwielder RH, Wesseling M, Hoefer IE, Tiel Groenestege WM. Ionized and not total magnesium as a discriminating biomarker for hypomagnesaemia in continuous venovenous haemofiltration patients. Nephrol Dial Transplant 2021; 36(4): 742–3.
30. Swaminathan R. Magnesium metabolism and its disorders. Clin Biochem Rev 2003; 24(2): 47–66.
31. Limaye CS, Londhey VA, Nadkart MY, Borges NE. Hypomagnesemia in critically ill medical patients. J Assoc Physicians India 2011; 59: 19–22.
32. Upala S, Jaruvongvanich V, Wijarnpreecha K, Sanguankeo A. Hypomagnesemia and mortality in patients admitted to intensive care unit: a systematic review and meta-analysis. QJM 2016; 109(7): 453–9.
33. Soliman HM, Mercan D, Lobo SS, Mélot C, Vincent JL. Development of ionized hypomagnesemia is associated with higher mortality rates. Crit Care Med 2003; 31(4): 1082–7.
34. Haider DG, Lindner G, Ahmad SS, Sauter T, Wolzt M, Leichtle AB. et al. Hypermagnesemia is a strong independent risk factor for mortality in critically ill patients: results from a cross-sectional study. Eur J Intern Med 2015; 26(7): 504–7.
35. Aal-Hamad AH, Al-Alawi AM, Kashoub MS, Falhammar H. Hypermagnesemia in Clinical Practice. Medicina 2023; 59(7): 1190.
2. Guiet-Bara A, Durlach J, Bara M. Magnesium ions and ionic channels: activation, inhibition or block - a hypothesis. Magnes Res 2007; 20(2): 100–6.
3. Elin RJ. Assessment of magnesium status for diagnosis and therapy. Magnes Res 2010; 23(4): S194–198. doi: 10.1684/mrh.2010.0213.
4. Hermes Sales C, Azevedo Nascimento D, Queiroz Medeiros AC, Costa Lima K, Campos Pedrosa LF, Colli C. There is chronic latent magnesium deficiency in apparently healthy university students. Nutr Hosp 2014; 30(1): 200–4.
5. Stanojević M, Djuricic N, Parezanovic M, Biorac M, Pathak D, Spasic S. et al. The Impact of Chronic Magnesium Deficiency on Excitable Tissues-Translational Aspects. Biol Trace Elem Res 2024. Epub ahead of print.
6. Broner CW, Stidham GL, Westenkirchner DF, Tolley EA. Hypermagnesemia and hypocalcemia as predictors of high mortality in critically ill pediatric patients. Crit Care Med 1990; 18(9): 921–8.
7. Dabla PK, Sharma S, Dabas A, Tyagi V, Agrawal S, Jhamb U. et al. Ionized Blood Magnesium in Sick Children: An Overlooked Electrolyte. J Trop Pediatr 2022; 68(2): fmac022.
8. Cheungpasitporn W, Thongprayoon C, Qian Q. Dysmagnesemia in Hospitalized Patients: Prevalence and Prognostic Importance. Mayo Clin Proc 2015; 90(8): 1001–10.
9. Baker SB, Worthley LI. The essentials of calcium, magnesium and phosphate metabolism: part II. Disorders. Crit Care Resusc 2002; 4(4): 307–15.
10. Huijgen HJ, Soesan M, Sanders R, Mairuhu WM, Kesecioglu J, Sanders GT. Magnesium levels in critically ill patients. What should we measure? Am J Clin Pathol 2000; 114(5): 688–95.
11. Gonuguntla V, Talwar V, Krishna B, Srinivasan G. Correlation of Serum Magnesium Levels with Clinical Outcome: A Prospective Observational Study in Critically Ill Patients Admitted to a Tertiary Care ICU in India. Indian J Crit Care Med 2023; 27(5): 342–7.
12. Scarpati G, Baldassarre D, Oliva F, Pascale G, Piazza O. Ionized or Total Magnesium levels, what should we measure in critical ill patients? Transl Med UniSa 2020; 23: 68–76.
13. Stanojević M, Lopičić S, Spasić S, Nedeljkov V, Prostran M. Antiepileptičko dejstvo magnezijuma / Antiepileptic magnesium effect. Medicinska istraživanja / Medical investigations 2017; 51(3): 20–8.
14. Fiser RT, Torres AJr, Butch AW, Valentine JL. Ionized magnesium concentrations in critically ill children. Critical Care Medicine 1998; 26(12): 2048–52.
15. Khilnani P. Electrolyte abnormalities in critically ill children. Crit Care Med 1992; 20(2): 241–50.
16. Kyriacou L. Monitoring of serum total and ionised magnesium in patients with acute myocardial infarction. Australian Journal of Medical Science 2008; 29(3): 84–90.
17. Yeh DD, Chokengarmwong N, Chang Y, Yu L, Arsenault C, Rudolf J. et al. Total and ionized magnesium testing in the surgical intensive care unit - Opportunities for improved laboratory and pharmacy utilization. J Crit Care 2017; 42: 147–51.
18. Johansson M, Whiss PA. Weak relationship between ionized and total magnesium in serum of patients requiring magnesium status. Biol Trace Elem Res 2007; 115(1): 13–21.
19. Dacey MJ. Hypomagnesemic disorders. Crit Care Clin 2001; 17(1): 155–73.
20. DePriest J, Dodson C, Phelps B. The Impact of Regional Citrate Anticoagulation on Magnesium Replacement During CRRT. Hosp Pharm 2023; 58(3): 255–8.
21. Matsuura C, Kato T, Koyama K. Successful Management of Refractory Torsades De Pointes Due to Drug-Induced Long QT Syndrome Guided by Point-of-Care Monitoring of Ionized Magnesium. Cureus 2021; 13(3): e13939.
22. Wilkes NJ, Mallett SV, Peachey T, Di Salvo C, Walesby R. Correction of ionized plasma magnesium during cardiopulmonary bypass reduces the risk of postoperative cardiac arrhythmia. Anesth Analg 2002; 95(4): 828–34.
23. Xue W, You J, Su Y, Wang Q. The Effect of Magnesium Deficiency on Neurological Disorders: A Narrative Review Article. Iran J Public Health 2019; 48(3): 379–87.
24. Lozada-Martinez ID, Padilla-Durán TJ, González-Monterroza JJ, Aguilar-Espinosa DA, Molina-Perea KN, Camargo-Martinez W. et al. Basic considerations on magnesium in the management of neurocritical patients. Journal of neurocritical care 2021; 14(2): 78–87.
25. Broman M, Hansson F, Klarin B. Analysis of hypo- and hypermagnesemia in an intensive care unit cohort. Acta Anaesthesiol Scand 2018; 62(5): 648–57.
26. Lee JW. Fluid and electrolyte disturbances in critically ill patients. Electrolyte Blood Press 2010; 8(2): 72–81.
27. Curran J, Ross-White A, Sibley S. Magnesium prophylaxis of new-onset atrial fibrillation: A systematic review and meta-analysis. PLoS One 2023; 18(10): e0292974.
28. Meerman M, Buijser M, van den Berg L, van den Heuvel AM, Hoohenkerk G, van Driel V. et al. Magnesium sulphate to prevent perioperative atrial fibrillation in cardiac surgery: a randomized clinical trial: A protocol description of the PeriOperative Magnesium Infusion to Prevent Atrial fibrillation Evaluated (POMPAE) trial. Trials 2024; 25(1): 540.
29. Hutten TJA, Sikma MA, Stokwielder RH, Wesseling M, Hoefer IE, Tiel Groenestege WM. Ionized and not total magnesium as a discriminating biomarker for hypomagnesaemia in continuous venovenous haemofiltration patients. Nephrol Dial Transplant 2021; 36(4): 742–3.
30. Swaminathan R. Magnesium metabolism and its disorders. Clin Biochem Rev 2003; 24(2): 47–66.
31. Limaye CS, Londhey VA, Nadkart MY, Borges NE. Hypomagnesemia in critically ill medical patients. J Assoc Physicians India 2011; 59: 19–22.
32. Upala S, Jaruvongvanich V, Wijarnpreecha K, Sanguankeo A. Hypomagnesemia and mortality in patients admitted to intensive care unit: a systematic review and meta-analysis. QJM 2016; 109(7): 453–9.
33. Soliman HM, Mercan D, Lobo SS, Mélot C, Vincent JL. Development of ionized hypomagnesemia is associated with higher mortality rates. Crit Care Med 2003; 31(4): 1082–7.
34. Haider DG, Lindner G, Ahmad SS, Sauter T, Wolzt M, Leichtle AB. et al. Hypermagnesemia is a strong independent risk factor for mortality in critically ill patients: results from a cross-sectional study. Eur J Intern Med 2015; 26(7): 504–7.
35. Aal-Hamad AH, Al-Alawi AM, Kashoub MS, Falhammar H. Hypermagnesemia in Clinical Practice. Medicina 2023; 59(7): 1190.
Published
2025/01/13
Section
Review article
Copyright (c) 2025 Marija Stanojević
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