Fatal systemic magnesium intoxication followed the administration of a magnesium sulfate enema for the therapy of presumed hyaline membrane disease in a newborn infant. Despite antemortem recognition of its occurrence and attempted therapy with an exchange transfusion, the infant died. Coupled with a lack of any demonstrable efficacy of this therapy for hyaline membrane disease, the toxicity is such as to prohibit its further use.
Outerbridge EW, Papageorgiou A, Stern L. Magnesium Sulfate Enema in a NewbornFatal Systemic Magnesium Absorption. JAMA. 1973;224(10):1392–1393. doi:10.1001/jama.1973.03220240042010
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