High‐Dose Vitamin B12 in Vasodilatory Shock: A Narrative Review

Abstract

Vasodilatory shock, as observed in postoperative states and sepsis, is hallmarked by low systemic vascular resistance and low blood pressure compensated by increased cardiac output. Gasotransmitters, such as nitric oxide and hydrogen sulfide, are implicated in the development and perpetuation of vasodilatory shock. Established therapies do not target these physiologic drivers of vasodilation. Due to their nontoxic and pleotropic effects, micronutrients are being used as rescue therapy in postoperative vasoplegia and septic shock. Here, we outline the pathophysiology of vasodilatory shock, describe the rationale for vitamin B12 (hydroxocobalamin) in vasodilatory shock, and identify literature evaluating its use in vasoplegic states. (Nutr Clin Pract. 2019;34:514-520)

Cobalt Blues: A New Complication of Hydroxocobalamin Therapy for Vasopressor-Resistant Vasoplegia in Patients Treated With Chronic Renal Replacement Therapy?

“…5 The mechanisms by which hydroxocobalamin increases arterial pressure are incompletely understood, but the vitamin is known to scavenge, bind, and prevent the formation of nitric oxide, carbon monoxide, and hydrogen sulfide, gasotransmitters that regulate vascular smooth muscle tone and capillary permeability through endothelium-dependent and endothelium-independent pathways. 6,7 It is noteworthy that abnormal regulation of nitric oxide and hydrogen sulfide also is strongly implicated in the pathogenesis of vasodilatory shock, including vasopressorresistant vasoplegia associated with cardiopulmonary bypass and liver transplantation. 6,7 Because of its known hypertensive effects (along with its lack of serotonergic activity), hydroxocobalamin was first used by Roderique et al as a rescue treatment for vasopressor-resistant vasoplegia after prolonged cardiopulmonary bypass in a patient who was chronically receiving the antidepressant citalopram (a selective serotonin reuptake inhibitor) and who could not be treated with methylene blue because of the potential for serotonin syndrome.…”

“…6,7 It is noteworthy that abnormal regulation of nitric oxide and hydrogen sulfide also is strongly implicated in the pathogenesis of vasodilatory shock, including vasopressorresistant vasoplegia associated with cardiopulmonary bypass and liver transplantation. 6,7 Because of its known hypertensive effects (along with its lack of serotonergic activity), hydroxocobalamin was first used by Roderique et al as a rescue treatment for vasopressor-resistant vasoplegia after prolonged cardiopulmonary bypass in a patient who was chronically receiving the antidepressant citalopram (a selective serotonin reuptake inhibitor) and who could not be treated with methylene blue because of the potential for serotonin syndrome. 8 Since their report first appeared 5 years ago in the Annals of Thoracic Surgery, the use of hydroxocobalamin as a rescue treatment for vasodilatory shock has been described increasingly in a number of case reports and series, 6,7 including several from our group.…”

“…In addition to increases in arterial pressure, a number of other hydroxocobalamin side-effects merit comment, most of which are clinically benign. 6,7 The 2 most commonly encountered adverse effects are chromaturia and erythema, but headache, rash, photosensitivity, and allergic reactions, a few of which can be severe, also have been reported. 5 Red or dark orange chromaturia is ubiquitous in all patients after administration of hydroxocobalamin; this effect that may persist for as long as 4 weeks and interferes with urinalysis by falsely elevating urine pH, protein, and glucose.…”

Impact on Biological Markers of a B12 Hypervitaminosis In the Context of a Refractory Vasoplegic Shock Treatment

“…Vitamin B12 is used for several years in the treatment of pernicious anemia, but also at very high doses in cardiogenic or septic shock with major vasoplegic syndrome [1][2][3][4].…”

“…Thus, patients with a refractory shock state where significant vasoplegia is associated are sometimes treated, as a last resort, with vitamin B12 administered intravenously, with not clear toxicity described so far in the literature and promising results [1][2][3][4].…”