Large versus Small Dose Magnesium Sulfate Infusion in Tetanus

Abstract

Introduction: Evidence based guidelines regarding the use of magnesium sulfate in tetanus is lacking. Hence, our objective was to compare two infusion doses of magnesium sulfate to control the tetanic spasms. Methods: Data of 14 adult male patients admitted in the intensive care unit were retrieved. Twelve adult ventilated patients received magnesium infusion as an adjunct to diazepam therapy to control tetanic spasms. We retrospectively divided them into two groups for comparison. Group 1 patients (n=7) received a smaller dose (<1 g.h-1) than group 2 (n=5) (1.5 to 2 g.h-1). Results: The duration of symptoms before arrival to hospital was significantly longer in group 1 than group 2. The Ablett severity grade was II in three patients in group 1 and III in all patients of group 2. In Ablett severity grade III patients, the diazepam dose used was significantly higher in group 1 (n=4) (292±48 mg.d-1) than group 2 (n=3) (106±9 mg.d-1) as magnesium infusion dose was restricted due to hypotension in group 1. Amongst the patients who received MgSO4 for ≥10 days, the requirement of diazepam was significantly reduced in the second week (174.1±59.2 mg/d) than the first week (325.4±105.9 mg.d-1) of infusion in group 2 (n=4) but not in group 1 patients (n=4). Conclusions: The larger dose of MgSO4 infusion was titrated to control tetanic spasms as an adjunct to diazepam in select group of patients without hypotension. Uncontrolled hypotension, cardiac arrhythmia and renal failure were the factors to limit its infusion dose.Keywords: MgSO4; magnesium sulphate; tetanus.

A Review on Pharmacological Management of Generalised Tetanus

“…Intrathecal administration of baclofen had caused decrease muscle spasm in generalised tetanus. In a study by Santosh et al of 22 patient with grade III tetanus treated by intrathecal baclofen with bolus dose followed by 20 ug/hour, 21 patients recovered [17]. A similar finding was reported by the prospected study conducted by the Guglielmino et al that the use of intrathecal baclofen had a good response to treatment [18].…”

“…The therapeutic level of the magnesium sulphate to be maintained is 2-4 meq/L [19]. The adverse effects of magnesium therapy were hypocalcemia, hypotension, arrhythmia, respiratory depression and renal failure [17,20,22]. Based on the above evidence, Magnesium sulphate can be used as an adjunctive to other therapy to control muscle spasm and autonomic instability in a patient with generalised tetanus.…”

Safety and efficacy of Magnesium Sulfate in the management of Tetanus: A systematic review

“…Kole et al had 86 patients in both the IV magnesium and IV diazepam group [19]. Pokharel et al had had 7 patients in the low-dose IV magnesium group and 5 in the larger dose IV magnesium group [18]. The rest of the observational studies had no control group but a single IV magnesium group with a sample size ranging from 10 to 44 (Table 1).…”

“…The severity of tetanus was assessed by Ablett's grading in all included studies [21] [9,15,16,18,19]. The severity of tetanus in the control group was similar to that of the magnesium group in all studies that had a control group.…”

“…When comparing magnesium-only with diazepam-only therapy for the treatment of tetanus regarding mortality, Ali et al and Osalusi et al demonstrated no statistically significant difference in mortality rate [9,10]. In the Pokharel et al study that compared groups receiving higher and lower doses of magnesium therapy in addition to diazepam, 2 of 7 patients died in the low-dose group, while 0 of 7 patients died in the higher dose group [18]. Mortality rates in the Kole et al study varied based on severity before treatment.…”