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CC BY-NC-ND 4.0 · Asian J Neurosurg
DOI: 10.1055/s-0045-1809355
Case Report

Unraveling NAGMA: A Case Series of Intravenous Nimodipine-Induced Metabolic Acidosis in Neuro-ICU Patients

Umadevi Manyam
1   Department of Neuroanaesthesiology and Neurocritical Care, All India Institute of Medical Sciences, New Delhi, India
,
Sivakumar Ramalingam 
1   Department of Neuroanaesthesiology and Neurocritical Care, All India Institute of Medical Sciences, New Delhi, India
,
Deepak Nandwana
2   Department of Neuroanaesthesia and Neurocritical Care, CK Birla Hospital, Jaipur, Rajasthan, India
,
Dineshkumar Ramanathan
1   Department of Neuroanaesthesiology and Neurocritical Care, All India Institute of Medical Sciences, New Delhi, India
,
Varun Chelani
1   Department of Neuroanaesthesiology and Neurocritical Care, All India Institute of Medical Sciences, New Delhi, India
,
Keshav Goyal 
1   Department of Neuroanaesthesiology and Neurocritical Care, All India Institute of Medical Sciences, New Delhi, India
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Abstract

Nimodipine, a calcium channel blocker of the dihydropyridine class, is used prophylactically in ruptured aneurysmal subarachnoid hemorrhage (aSAH) patients to reduce the incidence of poor outcome, delayed cerebral ischemia, and delayed ischemic neurological deficits. This case series reports nine instances of normal anion gap metabolic acidosis (NAGMA) in patients with aSAH following intravenous nimodipine administration in a neuro-intensive care unit (NICU) over 2 months. The patients, aged 4 to 68 years (seven male, two female), presented with acute headaches and were diagnosed with intracranial aneurysms, managed with aneurysmal clipping or coiling. Intravenous nimodipine (1–2 mg/hour) was initiated as per protocol, along with standard NICU care. After 48 to 72 hours, patients developed hyperventilation, respiratory alkalosis, and a significant decrease in bicarbonate, leading to NAGMA. Despite ruling out common causes like gastrointestinal losses and nephrotoxic drugs, renal tubular acidosis was suspected. The NAGMA resolved spontaneously 6 to 7 days postsurgery, coinciding with the discontinuation of intravenous nimodipine. A retrospective audit revealed a common factor: using a specific brand of intravenous nimodipine, a new arrival from the hospital supply. This phenomenon was later corroborated in a similar case from another hospital. The case highlights the importance of pharmacovigilance, postmarketing surveillance, and regulatory oversight in identifying rare drug-related adverse events, particularly in high-acuity settings like NICU.

Keywords

NAGMA (normal anion gap metabolic acidosis) - nimodipine - adverse drug events - pharmacovigilance - aneurysmal subarachnoid hemorrhage

Note

The manuscript has been read and approved by all the authors, the requirements for authorship, as stated earlier in this document, have been met, and each author believes that the manuscript represents honest work.


Authors' Contributions

All authors contributed equally to the article and have fulfilled various criteria qualifying them for inclusion in the authors' list. Their contributions span multiple key areas of the research and manuscript development process. All authors contributed to the concepts, design, definition of intellectual content, literature search, clinical and experimental studies, data acquisition, data analysis, statistical analysis, and manuscript preparation. In addition to these, they also took part in manuscript editing and manuscript review. K.G. is the guarantor for the manuscript. These contributions reflect substantial involvement by each author across multiple stages of the study and publication process, thereby justifying their authorship in accordance with standard publishing guidelines.




Publikationsverlauf

Artikel online veröffentlicht:
26. Mai 2025

© 2025. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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