Con: Methylene Blue Should Not Be Used Routinely for Vasoplegia Perioperatively

Pharmacologic agents for acute hemodynamic instability: Recent advances in the management of perioperative shock- A systematic review

“…[ 78 79 ] The incidence of vasoplegic syndrome in cardiac surgery varies but has been reported as high as 42% in comorbid patients undergoing ventricular assist device placement[ 80 ] and the mortality may be as high as 25%. [ 81 ] Methylene blue has been used as a rescue agent for perioperative vasoplegic syndrome in multiple clinical scenarios including cardiac surgery, protamine reaction, sepsis, and anaphylaxis. [ 81 82 83 84 ] It has even been used prophylactically in high-risk patients undergoing cardiac surgery.…”

“…[ 81 ] Methylene blue has been used as a rescue agent for perioperative vasoplegic syndrome in multiple clinical scenarios including cardiac surgery, protamine reaction, sepsis, and anaphylaxis. [ 81 82 83 84 ] It has even been used prophylactically in high-risk patients undergoing cardiac surgery. [ 79 ] Suggested risk factors for perioperative vasoplegic syndrome in cardiac surgery have been reviewed, and include preoperative LV ejection fraction <35%, ventricular assist device implantation, prolonged CPB, and the preoperative use of intravenous heparin, angiotensin-converting enzyme inhibitors, calcium channel blockers, and beta-blockers.…”

“…[ 79 ] Suggested risk factors for perioperative vasoplegic syndrome in cardiac surgery have been reviewed, and include preoperative LV ejection fraction <35%, ventricular assist device implantation, prolonged CPB, and the preoperative use of intravenous heparin, angiotensin-converting enzyme inhibitors, calcium channel blockers, and beta-blockers. [ 81 ] The dose of methylene blue varies in the literature but in cardiac surgery, a dose of 1.5–2.0 mg/kg IV infused over 1 h is generally acceptable. [ 85 86 ] In some cases, this initial bolus is followed by a continuous infusion.…”

“…Methylene blue has a rapid onset, but unlike most vasoactive agents, it has a long half-life of approximately 5.25 h.[ 87 ] It is eliminated by the kidney and is contraindicated in renal failure and should be avoided in patients with known glucose-6-phosphate dehydrogenase deficiency. [ 81 ] Adverse effects have been reviewed and include transient color change of the skin and urine to greenish-blue, cardiac arrhythmias (transient nodal rhythm and ventricular ectopy), coronary vasoconstriction, decreased CO, increased PVR, and decreased renal and mesenteric blood flow; however, these effects were transient and dose dependent (usually at doses >2 mg/kg). [ 81 ] Although the use of perioperative methylene blue is currently controversial,[ 88 ] a recent meta-analysis of randomized controlled trials in hypotensive patients demonstrated no harm.…”

“…[ 81 ] Adverse effects have been reviewed and include transient color change of the skin and urine to greenish-blue, cardiac arrhythmias (transient nodal rhythm and ventricular ectopy), coronary vasoconstriction, decreased CO, increased PVR, and decreased renal and mesenteric blood flow; however, these effects were transient and dose dependent (usually at doses >2 mg/kg). [ 81 ] Although the use of perioperative methylene blue is currently controversial,[ 88 ] a recent meta-analysis of randomized controlled trials in hypotensive patients demonstrated no harm. [ 89 ] Therefore, due to the high mortality associated with perioperative vasoplegic syndrome, the use of methylene blue as a rescue agent should be considered in the setting of refractory hypotension.…”