Which medication would the nurse anticipate administering to a client experiencing toxicity caused by magnesium sulfate in preterm labor management?

• Criteria for use of magnesium sulfate are established.
  • Medical indications for use vary. Several professional organizations, guidelines, and evidence reviews offer examples of maternal and fetal conditions that may be indications for use of magnesium sulfate.1-7
  • Absence of contraindications for magnesium sulfate are verified and documented. Contraindications on the manufacturer’s drug label include8—
    • Patients with heart block.
    • Patients with myocardial damage.
    • In addition, the FDA and professional organizations offer warnings against use of magnesium sulfate longer than 5 to 7 days because of risk of fetal and neonatal bone demineralization and fractures.3,9
    • Staff with requisite training and supplies available to respond to magnesium-related adverse events, for example respiratory depression.10,11

• Unit-established process for using manufacturer’s premixed bags or pharmacy-prepared bags of magnesium sulfate for both loading dose (bolus) and maintenance infusion.
• Medication errors are more common in unit-prepared bags, so this practice should be avoided.12
• Pharmacy and nursing staff should use a consistent approach to labeling all magnesium sulfate bags and tubing used to administer the medication.11

• Limit the number of different kinds of infusion pumps to maximize staff familiarity with infusion equipment.10
• Establish the unit’s standard approach for administering a loading dose (bolus). Use of the maintenance infusion to administer a bolus manually is a high-risk practice that should be avoided. Safe dosing options include—
  • Administering the bolus from the maintenance infusion using a "smart" infusion pump that has the following safety features:10
    • Pump includes a bolus dose feature that allows programming to automatically switch to the continuous infusion rate at the end of the bolus AND staff are trained to use this feature.
    • Separate dose limits can be set for bolus doses and maintenance doses.
    • Dose limit alerts are operational at all times.
    • Dose limit alerts are configured as a "hard stop," requiring pump to be reprogrammed if dose exceeds limits.
  • If a smart infusion pump with these safety features is not available, then loading dose should be administered via a separate bag. Premixed or pharmacy-prepared bags (e.g., 4 g/100 ml or 8 g/100 ml) should be used unitwide to reduce variability and risk of error.
• The same standard preparation either premixed or pharmacy-prepared bags (e.g., 20 g/500-ml bag) unitwide for maintenance infusion.13
  • Use of a 500-ml bag can help distinguish the bag from liter bags containing fluids or other medications.11
  • The smaller volume also reduces the amount of magnesium that can be delivered in the event of an accidental rapid infusion (e.g., pump programming error or failure).
• Complete removal of the line from the intravenous (IV) port when magnesium sulfate therapy is discontinued to avoid accidental infusion.10,11

• Indications for use (e.g., neuroprotection of fetus during preterm labor, seizure prophylaxis for preeclampsia).
• Contraindications for use.
• Maternal status prior to initiation.
• Fetal status prior to initiation.

• Assessment prior to initiation: Vital signs, deep tendon reflexes/clonus, level of consciousness, symptoms such as headache, visual disturbances, nausea/vomiting, epigastric pain, tocography, and fetal heart rate (FHR) (antepartum and intrapartum only).
• Assessment during infusion: Vital signs, with specific focus on oxygen saturation and respiratory pattern, deep tendon reflexes, fluid intake/output, tocography, signs and symptoms of labor progression, worsening signs/symptoms of preeclampsia, magnesium toxicity, and fluid overload. Typically, a nurse should remain at the bedside during the loading dose to monitor initial response and reassure patient regarding commonly experienced side effects.
• Use of serum magnesium levels: Regular, routine serum levels do not always correlate with clinical symptoms and are not needed for most patients. However, regular, routine serum levels may be useful for patients with impaired renal function.

• Provider-notification criteria can be based on patient vital signs, FHR patterns, and signs and symptoms of labor progression, worsening signs/symptoms of preeclampsia, magnesium toxicity, or labor progression. Various clinical reviews and references offer some suggested parameters for notification.10,15

• Know how to recognize the signs and symptoms of toxicity.
• Have ready access to the antidote, calcium gluconate, via a kit stored in the patient’s room or easily accessible on the unit.
• Know how to temporarily support ventilation and activate a rapid response for advanced airway support.

Standing orders for nurse response for signs and symptoms of magnesium toxicity can include—

• Activating a rapid response (i.e., call for additional help).
• Stopping the infusion.
• Monitoring vital signs, including oxygen saturation and respiratory rate and pattern.
• Drawing a STAT magnesium blood level.
• If respiration is depressed, administering oxygen by face mask and administering calcium gluconate to antagonize the effects of excessive magnesium levels.
• If respiration is arrested, supporting ventilation with bag-valve-mask, administering calcium gluconate, and activating request for advanced airway support.

• Unit can decide its approach to debriefing events based on seriousness of event, expertise available, and data monitoring and tracking capabilities.
  • Informal debriefings by clinical team immediately following event using an approach that does not shame or blame individuals. This approach allows for understanding of what went well, what could have gone better, and what could be done differently next time.
  • Regular forum with a multidisciplinary team can help the unit learn from defects and sensemaking using the following tools:
    • Discovery form.
    • Root cause analysis.
    • Eindhoven model.
    • Failure mode and effects analysis.
    • Probabilistic risk assessment.
    • Causal tree worksheet.
    • Interdisciplinary case reviews.

A sample process and forms for a committee review are available at the Council on Patient Safety in Women’s Health Care, www.safehealthcareforeverywoman.org.
Select "Get SMM Forms."

• Magnesium sulfate toxicity.
• Preeclampsia/seizure.

• Two sample scenarios available through the Safety Program for Perinatal Care can be used to train teams on the key perinatal safety elements related to magnesium sulfate use. This scenario reinforces teamwork and communication related to—
  • Situational awareness.
  • Ability to get additional help quickly.
  • Timely use of standing orders for managing magnesium sulfate toxicity.
  • Communication with rapid responders.
  • Communication with patient/family.
  • Using of briefings, huddles, and debriefings.

• Knowing what the patient's plan is through briefings and team management.
• Being aware of what is going on and what is likely to happen next.
• Verifying and checking back on information.
• Providing ongoing updates.

In the context of magnesium sulfate use, this includes staff alertness for early signs of abnormal fetal or maternal status, and knowing the plan for a timely response to prevent further deterioration.

• For communicating a sense of urgency when requesting other unit personnel and provider for help responding to sudden changes in maternal or fetal status (e.g., seizure, magnesium toxicity, fetal distress).
• For communicating changes in maternal or fetal status.
• When giving and receiving new orders to manage sudden changes in maternal or fetal status.
• When briefing new care team members who arrive to support a rapid response.
• When regrouping to discuss plan of care if patient fails to respond to initial measures.

• Anyone can sound an alarm, request help, or challenge the status quo.
• Hierarchy is minimized.
• Communication is continuous, valued, and expected.

• Team members protect each other from work overload and place requests or offers for assistance in the context of patient safety. It is expected that assistance will be actively sought and offered.
• Team members will advocate for the patient when one person's viewpoint does not coincide with another's.
  • Assert a corrective action in a firm and respectful manner.
  • Use CUS language: "I am concerned. I am uncomfortable. This is a safety issue."
  • Use the Two Challenge rule and repeat the concern and inquire whether concern has been heard.
  • Use a predetermined "stop the line" phrase.
• Manage conflict using a constructive positive approach to emphasize "what is right, not who is right":
  • D: Describe the specific behavior or situation.
  • E: Express how the situation makes you feel or concerns you.
  • S: Suggest other alternatives.
  • C: Consequences stated in terms of team goals, not punishment.

• Use unit-established approach for nursing-led patient education regarding magnesium sulfate infusion, mobility restrictions, and expected effects.
• Educate patient and family concerning frequency of nursing assessment and monitoring, signs and symptoms to report to nursing staff.
• Provide instructions for reporting signs and symptoms to nursing staff.

• Indications for use:1-7
  • Neuroprotection of fetus before anticipated early preterm delivery (< 32 weeks gestational age).
  • Seizure prophylaxis or treatment in women with preeclampsia or eclampsia.
  • Use as a tocolytic for up to 48 hours for short-term prolongation of pregnancy for the administration of antenatal corticosteroids in women between 24 and 34 weeks gestation who are at risk of preterm delivery within 7 days.
• Contraindications for use:8
  • Use more than 5 to 7 days.
  • Patients with heart block.
  • Patients with myocardial damage.
• Staff with requisite training and supplies available to respond to magnesium-related adverse events including respiratory depression.

• Assessment prior to initiation: Vital signs (temperature, pulse, blood pressure, respiratory rate and pattern), deep tendon reflexes(DTRs)/clonus, breath sounds, level of consciousness, symptoms such as headache, visual disturbances, nausea/vomiting, epigastric pain, tocography, and fetal heart rate (FHR) pattern (antepartum and intrapartum only).
• Verify seizure precautions:
  • Oxygen and suction available at the bedside.
  • Bedrails in the upright position.
  • Patient is NPO (nothing by mouth).
• During loading dose: While the loading dose is being administered, the nurse should remain at the bedside to monitor the patient.
• Periodic nursing assessments: Every 15 minutes during first hour of infusion, every 30 minutes during second hour, and hourly thereafter. Assessments should include—
  • Vital signs (blood pressure, respirations [rate and pattern], pulse, temperature, oxygen saturation level).
  • DTRs and presence or absence of clonus.
  • Fluid inputs and outputs (if a patient cannot ambulate to the bathroom or use a bedpan, an indwelling urine catheter may be needed).
  • Level of consciousness.
  • Breath sounds.
  • Presence of headaches or visual disturbances (blurred or double vision).
  • Presence or absence of epigastric pain.
  • Presence of extravasation or infiltration at intravenous (IV) site.
  • Signs/symptoms of magnesium toxicity, worsening pre-signs or symptoms of eclampsia, or progression of labor.
  • Periodic urine assessment for protein (if applicable).
  • Vaginal bleeding.
  • Tocography and FHR (with antepartum or intrapartum use).
• Serum magnesium-level monitoring every 6 hours:
  ___YES (Patients with impaired renal function)
  ___NO (Patients with normal renal function)

• Administer the mainline fluids and magnesium sulfate using a calibrated infusion pump.
• Connect the magnesium sulfate medication bag into the mainline IV tubing by attaching it to the lowest port on an extension set or the lowest connector on the IV tubing set to facilitate immediate disconnection during emergencies.
• Initiate magnesium sulfate with a loading dose (bolus) using a premixed bag of 4 grams per 100 ml. Infuse the bolus dose over a 20- to 30-minute period.
• When bolus is complete, initiate a premixed maintenance bag with a concentration of 20 grams of per 500 ml. Administer maintenance infusion at a rate of (check one)—
  ___1 gram/hour (25 ml/hour)
  ___1.5 grams/hour (38 ml/hour)
  ___2 grams/hour (50 ml/hour)
  ___Other (separate provider order required for rates other than the above rates)
• Label the magnesium sulfate line with appropriate medication sticker.
• Do not infuse other medication into the magnesium sulfate line.
• Second nurse must verify pump settings and line hookup whenever there is a rate change or a new bag is hung.
• When the order for magnesium is discontinued, the pump should be stopped and the bag and IV tubing promptly disconnected from the patient and discarded.

• Magnesium toxicity is a clinical diagnosis, and serum levels do not always correlate with clinical signs and symptoms.

Adapted from Simpson, 2004.10

• Standing orders for suspected magnesium sulfate toxicity:
  • Stop the infusion.
  • Activate a rapid response and notify provider.
  • Monitor respiratory rate, pattern, and monitor oxygen saturation with pulse oximeter.
  • Draw a STAT serum magnesium level.
  • If respiration is depressed, administer oxygen 2L by face mask and administer calcium gluconate 1 gm (10 ml of a 10% solution) over 5 minutes.
  • If respiration arrests, request advanced airway support and bag-valve-mask to support respiration.

• Discuss risks and benefits of magnesium sulfate with patient and family.
• Explain the magnesium infusion procedure, mobility, and dietary restrictions.
• Explain expected therapeutic effects, and discuss likely side effects, and symptoms of toxicity that should be reported immediately.
• Discuss how patient and family can request urgent assistance if nurse is not at bedside.
• Place lights in the patient’s room on low.
• Maintain a quiet environment.
• Provide a fan at the bedside for relief from flushing, hot flashes, and sensation of increased body temperature.

• Notify pediatrics when antepartum and intrapartum patients are placed on magnesium sulfate.
• Verify medication bag, pump settings, and IV tubing are correct during change of shifts or other transitions of care team.
• Use TeamSTEPPS communication techniques to—
  • Request urgent additional help.
  • Assert and advocate for safe practices (CUS).
  • Brief new team members, such as during a rapid response (SBAR).
  • Acknowledge receipt of orders (closed-loop communication).
  • Maintain situational awareness by sharing new information with team as it is learned.