Le magnésium est un cation majoritairement intracellulaire. Il n’y a que 1% du pool magnésien en extracellulaire. On peut globalement retenir que le magnésium a un effet inhibiteur calcique. L’administration de magnésium peut être utile comme adjuvant aux médicaments permettant une anesthésie générale.
Beaucoup d’études montrent une association entre l’hypomagnésémie et la morbi-mortalité en péri-opératoire ou en soins intensifs. Comme le répète toujours Dominique Dupagne avec ses #StatsALaCon dans La Tête au Carré (#LaTac) corrélation n’est pas causalité ! Ca n’est pas parce qu’on meurt souvent dans un lit que les lits sont dangereux ! Fin de l’a parte 😉 Néanmoins ces résultats donnent envie de rechercher dans la physiologie et de proposer des essais thérapeutiques. De plus il est fréquent de voir en post-opératoire des traitements pouvant favriser une hypomagnésémie : diurétiques, gentamycine et ciclosporine notamment.
A l’échelle cellulaire le magnésium influence lourdement la machinerie énergétique cellulaire et les échanges ioniques soit transmembranaires soit intracellulaires entres certains organites et le cytoplasme. On peut retenir que le magnésium a un effet stabilisant de membrane.
Sa répartition dans l’organisme rend peu utile les dosages plasmatiques (ou intracellulaire) en routine.
L’impact du magnésium sur le muscle lisse impose de la prudence dans son administration car le relâchement du muscle lisse peut se manifester sous forme d’un collapsus tensionnel. Je préfère ainsi les administrations progressives et j’évite de mettre un bolus de magnésium en même temps que l’induction anesthésique.
Le magnésium va également avoir un intérêt dans l’analgésie per et postopératoire. Il contribue avec la kétamine à bloquer le canal NMDA.
J’utilise donc le magnésium en anesthésie pour ces deux raisons principales : j’espère limiter le risque de passage en fibrillation auriculaire chez les patients à risque (OG dilatée, chirurgie lourde, thoracotomie) et je pense qu’il participe à l’analgésie.
Les autres raisons qui me poussent à utiliser du magnésium sont les suivantes :
- limiter le risque d’hypokaliémie, je préfère une kaliémie normale/haute à une kaliémie normale/basse
- faciliter la reprise du transit en chirurgie digestive (épargne morphinique + effet propre stimulant le transit)
- relâchement du muscle bronchique, les fumeurs et les patients BPCO sont de bons candidats au magnésium en périopératoire
- participe à la prévention du frisson post-opératoire
- en cas d’utilisation de fluoroquinolones (bouh!) il semblerait que le magnesium puisse avoir un effet protecteur sur les effets indésirables tendineux
- potentialiser le relâchement musculaire, notament si le patient a une contre-indication aux curares
- peut-être une place dans la chirurgie du phéochromocytome (mais la littérature me laisse un peu dubitatif)
- les rapport coût/bénéfice et bénéfice/risques me paraissent très favorable
Attention à particulièrement bien surveiller le bloc-neuromusculaire lorsque l’on utilise des curares et du magnésium. Le magnésium potentialise l’action des curares.
Je vous conseille particulièrement la lecture de la revue de la littérature par le Pr Dubé que vous trouverez dans la biblio ci-dessous.
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9 réponses sur « Magnésium et anesthésie »
Merci pour ce post sur le magnésium qui reste bien méconnu au bloc… Vous suggérez quelles doses et à quel moment de la chir du coup ? En pré per ou post op ? Merci d’avance !
L’article de revue que je met en exergue répondra précisément à vos questions.
En pratique, je mets 10 ml (une ampoule) de MgSO4 à 15% dans le deuxième et le troisième Ringer Lactate que j’infuse au bloc. Selon le gabarit du patient je peux doubler cette dose en continuant sur le même rythme.
Je préfère cette stratégie à l’administration en bolus au départ parce que je trouve le rapport bénéfice/risque meilleur, notamment vis à vis du risque de collapsus du fait de l’effet inhibiteur calcique du Mg2+
A propos du risque de potentialisation des curares, je vous renvoie vers une étude sympa sur le sujet de l’équipe de l’université de Liège. Un bolus de magnésium (50 mg/Kg) est administré chez des patients en cours de décurarisation (TOF>0,9) : ils se « recurarisent » (le TOF redescend à 0,45) pour … 45 minutes ! Cette étude montre d’une façon élégante que le magnésium prolonge le bloc neuro-musculaire. Par contre, le magnésium n’accélère pas l’installation du bloc neuro-musculaire :-).
« Intravenous magnesium re-establishes neuromuscular block after spontaneous recovery from an intubating dose of rocuronium : a randomised controlled trial. »
Gregory A. Hans, Besongo Bosenge, Vincent L. Bonhomme, Jean F. Brichant, Ingrid M. Venneman and Pol C. Hans in Eur J Anaesthesiol 2012; 29:95–99
merci Didier pour cette intéressante info complémentaire
Ah encore, je voudrais ajouter que je préfère le sulfate au chlorure … le chlore, c’est pour les piscines. LOL
yep le chlorure c’est pas top pour le rein, mais dans le cas de l’hypokaliémie je pense que c’est pas mal : http://www.nfkb0.com/2012/12/09/magnesium-et-hypokaliemie/
[…] Optimiser les désordres hydro-électrolytiques, je préfère une kaliémie à 5 qu’à 3 mmol/l et j’ai la supplémentation en magnésium facile (cf la note ad hoc) […]
Bonjour, y a t il une utilité à faire de la ketamine et du magnésium étant donné qu’ils agissent tous les deux sur les récepteurs NMDA?
Bonjour, l’utilité du magnésium pour l’analgésie est peu ou pas démontrée dans la littérature. Je l’utilise pour les autres propriétés décrites dans ce billet.