Improvement in Hemodynamics After Methylene Blue Administration in Drug-Induced Vasodilatory Shock: A Case Report

Laes, JoAn R.; Williams, David M.; Cole, Jon B.

doi:10.1007/s13181-015-0500-1

Cited by 23 publications

(19 citation statements)

References 26 publications

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“…Each of these patients was treated with methylene blue with rapid resolution of hypotension, but no systematic evaluation for other neurocardiogenic sequelae of aSAH such as Takotsubo cardiomyopathy, impaired left ventricular function, and/or myocardial ischemia was performed ( 9 ). Methylene blue is a recognized therapy for vasoplegia refractory to vasopressors ( 9 – 11 , 15 , 16 ), and its use has also been described in amlodipine overdose ( 15 ). It blocks accumulation of cyclic guanosine monophosphate (cGMP) via inhibition of guanylate cyclase activity, acts as a NO scavenger, and inhibits endothelial NO synthase activity, thereby decreasing responsiveness of cGMP-regulated vasodilation activated by NO ( 11 , 15 ).…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, only one case series (four patients) exists in the literature describing refractory vasoplegia secondary to nimodipine administration ( 9 ). Two agents thought to be effective rescue therapies in refractory vasoplegia due to their NO scavenging effects are methylene blue ( 9 – 11 , 15 , 16 ) and hydroxocobalamin (a highly bioavailable form of vitamin B12) ( 12 – 14 ). There are no randomized controlled studies comparing their effects nor reports of hydroxocobalamin as a rescue therapy in nimodipine-induced refractory vasoplegia.…”

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confidence: 99%

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Rescue of Nimodipine-Induced Refractory Vasoplegia With Hydroxocobalamin in Subarachnoid Hemorrhage: A Case Report

Clifford

Madhok

Murray

et al. 2020

Critical Care Explorations

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Background: We report a case of refractory vasoplegia after nimodipine administration that was unresponsive to triple vasopressor therapy and was rescued by IV hydroxocobalamin. Case Summary: An 84-year-old male presented comatose from a subarachnoid hemorrhage and developed severe hypotension unresponsive to three vasopressors following a single dose of enteral nimodipine. Multisystem point-of-care ultrasonography ruled out alternate etiologies of shock, indicating that this was likely a vasoplegic state caused by nimodipine. We administered 5 grams of IV hydroxocobalamin over 15 minutes due to the possibility of impaired nitric oxide metabolism as the driver of vasoplegia. This led to immediate improvement in hemodynamics and rapid discontinuation of vasopressors. The patient experienced chromaturia but no other adverse effects due to hydroxocobalamin. Conclusions: Nimodipine administration is a standard practice for patients with aneurysmal subarachnoid hemorrhage to reduce unfavorable outcomes from cerebral vasospasm. Although mild hypotension is a common side effect of nimodipine, in rare cases, it may become profound, leading to refractory vasoplegia. There is no evidence-base for reversal agents for nimodipine-induced vasoplegia, and this case is the first to demonstrate successful use of hydroxocobalamin as a potential rescue therapy. We also propose an algorithm for treatment of vasoplegia with consideration of medications that act on nitric oxide–mediated vasodilation and their side-effect profiles.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Rescue of Nimodipine-Induced Refractory Vasoplegia With Hydroxocobalamin in Subarachnoid Hemorrhage: A Case Report

Clifford

Madhok

Murray

et al. 2020

Critical Care Explorations

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“…By inhibiting the influx of calcium in smooth muscle cells, amlodipine prevents calcium-dependent myocyte contraction and vasoconstriction. [3] The site of action of dihydropyridine calcium channel blockers is primarily in the vasculature, thereby resulting in potent vasodilatory effects. The half-life of amlodipine is 30-50 hours, and the highest bioavailability is noted at 6-12 hours, therefore particular attention should be paid within the first few hours of ingestion.…”

Section: Discussionmentioning

confidence: 99%

“…[4] Methylene blue exhibits pharmacologic effects by inhibiting guanylyl cyclase, resulting in decreased cGMP production, thereby decreasing endothelial smooth muscle relaxation. [3] Therefore, it is logical that there is great utility for methylene blue use in this setting.…”

Section: Discussionmentioning

confidence: 99%

Hemodynamic improvement using methylene blue after calcium channel blocker overdose

Ahmed

Barnes

2019

World Journal of Emergency Medicine

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Calcium channel blocker overdoses are often fatal despite standard treatment. Methylene blue is a novel adjunct that should be considered in refractory cases. Currently accepted therapeutic modalities include intravenous fl uids, calcium, vasopressors and high-dose insulin euglycemic therapy, however shock may persist despite these treatment options. [1] Methylene blue has been utilized in sepsis, shock after cardiac surgery and other non-poisoning causes of shock. However, there are only ten human case reports and one animal study regarding its utility. The case reports describe its use in shock caused by quetiapine, valsartan and dihydropyridine calcium channel blockers, and measure the outcomes of hemodynamics and mortality. The animal study used a rat-model with thirty subjects treated with a lethal dose of amlodipine, followed by methylene blue or normal saline. Results revealed an increase in heart rate, mean arterial pressure (MAP) and median survival time in those treated with methylene blue. [2] E x pe r t c o n s e n s u s r e c o m m e n d a t i o n s f o r t h e management of calcium channel blocker poisoning in adults were recently assembled and did not recommend the use of methylene blue as first-line treatment, given that the experience was limited to a small number of case reports. [1] However, with additional case reports attesting to its effi cacy, there may be a role for methylene blue in the treatment of drug-induced vasodilatory shock. We present a case where methylene blue was administered to a patient suffering from refractory vasodilatory shock following toxic ingestion of amlodipine, resulting in subsequent hemodynamic improvement.

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“…In addition to use in septic shock, MB has also been studied in anaphylactic and drug-induced shock or undifferentiated shock [41][42][43][44][45][46]. Medications involved include contrast medium, antidiabetics, antidepressants, and antihypertensives (e.g., amlodipine, atenolol, and valsartan).…”

Section: Methylene Blue and Other Types Of Shockmentioning

confidence: 99%

Vasopressor-Sparing Action of Methylene Blue in Severe Sepsis and Shock: A Narrative Review

Puntillo

Giglio²,

Pasqualucci

et al. 2020

Adv Ther

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Shock is a serious acute circulatory failure leading to inadequate oxygen delivery to the cells. Its treatment is mainly based on circulating fluid optimization, and vasopressors to provide an adequate mean arterial pressure and microcirculatory flow. Norepinephrine is the drug of choice, but high dosages may be responsible for several side effects, including increased myocardial oxygen consumption, dysrhythmias, and peripheral and organ ischemia. Moreover, some patients are ''non-responders'' to first-line norepinephrine treatment. Hence, other drugs have been proposed to reach and maintain the hemodynamic target. In general, they are described as catecholaminesparing agents. Among others, the most used are vasopressin, corticosteroids, and angiotensin II. Methylene blue (MB) represents a further option, even though its use is still a topic of controversy. This review article tries to summarize what is known and unknown about the actions of MB in patients in shock. It reduces excessive production of nitric oxide via blockade of guanylate cyclase in shock states. At present, it appears the MB provides positive results in septic shock, if administered early. Further randomized controlled trials are warranted regarding its use to provide more precise indications to physicians involved in the treatment of such patients.

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Improvement in Hemodynamics After Methylene Blue Administration in Drug-Induced Vasodilatory Shock: A Case Report

Cited by 23 publications

References 26 publications

Rescue of Nimodipine-Induced Refractory Vasoplegia With Hydroxocobalamin in Subarachnoid Hemorrhage: A Case Report

Rescue of Nimodipine-Induced Refractory Vasoplegia With Hydroxocobalamin in Subarachnoid Hemorrhage: A Case Report

Hemodynamic improvement using methylene blue after calcium channel blocker overdose

Vasopressor-Sparing Action of Methylene Blue in Severe Sepsis and Shock: A Narrative Review

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