Effect of methylene blue on hemodynamic response in the early phase of septic shock: A case series

Abstract

Rationale: Methylene blue (MB) has been used to increase blood pressure in septic shock, acting on the activity of guanylate cyclase and nitric oxide synthase. Patience concerns: The aim of this study is to demonstrate the benefit of MB in early phase of septic shock. Diagnoses: We report 6 cases of patients with septic shock with up to 72 hours of evolution. Interventions: We used MB after fluid replacement, use of norepinephrine and vasopressin. Patients received a loading dose of MB and maintenance for 48 hours. Outcomes: All patients presented a reduction in the dose of vasopressors and lactate levels soon after the administration of the loading dose of MB, an effect that was maintained with the maintenance dose for 48 hours. Interleukin 6 and interleukin 8 were elevated at the beginning of the septic condition, with a progressive and marked reduction after the beginning of MB infusion, demonstrating a role of MB in reducing the inflammatory activity. Lessons: This case series suggests that MB used early in the treatment of septic shock may be useful in reducing vasopressor dose and lactate levels. Further studies are still required to further validate these findings.

Use of methylene blue in adult patients with septic shock: a systematic review and meta-analysis

“…In the setting of sepsis, in ammatory cytokines have been theorized to suppress the cortisol response or compete with intracellular glucocorticoid receptors, resulting in peripheral tissue resistance and eventual vascular collapse [37,38]. Low-dose corticosteroid therapy has been utilized in septic shock patients to enhance the vascular contractile response to pressor agents [39]. The utility of steroids was not explicitly described in any of the included studies, except for that of Ibarra-Estrada et al [25].…”

Methylene blue therapy versus standard treatment for acute-phase septic shock: a pilot randomized controlled trial

“…Treatment includes uid replacement, infusion of vasopressors, and administration of antibiotics within the rst hour [1]; these treatments are associated with low-dose corticosteroids in refractory cases [6], but mortality remains high, especially in developing countries. Studying new medications that help maintain hemodynamic stability until the antibiotic acts and combats the infectious focus is necessary [7].…”

“…Several studies have proposed that MB can treat circulatory shock secondary to vasoplegia via nitric oxide (NO) [7,8,[10][11][12][13][14][15]. In a rat model of endotoxemia induced by lipopolysaccharide (LPS) and treated with MB, complete prevention of leukocyte rolling and adhesion to the endothelium was observed, resulting in a consistent systemic blood pressure response and a decreased need for vasoactive medications [16].…”

“…In animal endotoxemia and in patients with septic shock, decreasing plasma levels of stable nitric oxide (NO) metabolites, nitrites, nitrates, and cGMP were demonstrated [1,10,12]. Although the medical literature does not include robust studies on the use of MB in septic shock, even with a small sample, the results are promising regarding the association of MB with conventional treatment in these patients [7,10,12]. In theory, the inhibition of excessive NO could act favorably, preventing systemic vasodilation and reducing microvascular injury in septic individuals.…”

“…Studies have shown the bene cial effects of MB in patients with septic shock [2,12,32]; however, studies involving patients in the acute phase are rare [7,10,12].…”