Methylene Blue and Vasoplegia: Who, When, and How?

Stawicki, Stanislaw P; Sims, Carrie A.; Sarani, Babak; Grossman, Michael D.; Gracias, Vicente H.

doi:10.2174/138955708784223477

Cited by 44 publications

(34 citation statements)

References 2 publications

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“…3 Methylene blue is also known for its NO binding capacity and treatment of vasoplegia associated with cardiopulmonary bypass. 40,41 Taken together, these data suggest that methylene blue is a potent inhibitor of NO production/action and is also associated with a profound vasoconstricting effect. This may maintain blood pressure in the setting of profound vasoplegia associated with cardiac surgery.…”

Section: Discussionmentioning

confidence: 84%

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Plasma methemoglobin as a potential biomarker of anemic stress in humans

Hare

Romaschin

et al. 2012

Can J Anesth/J Can Anesth

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Purpose Transfusion of allogeneic red blood cells (RBCs) is one of the main treatments of acute anemia secondary to blood loss and fluid resuscitation within the operating room. Decisions to transfuse blood are based largely on intermediate biological markers (hemoglobin, arterial oxygen saturation, blood pressure, heart rate) which may not accurately reflect inadequacy of tissue oxygen delivery.Based on experimental studies, we hypothesized that anemia-induced tissue hypoxia activates adaptive mechanisms which promote local vascular nitric oxide (NO) production to improve tissue perfusion and survival during acute anemia. Hemoglobin (Hb) oxidation to methemoglobin (MetHb) may be a byproduct of such local NO production. Therefore, we tested the hypothesis that MetHb is a biomarker of hypoxic-anemic stress during acute hemodilution associated with cardiopulmonary bypass. Methods With institutional ethics approval, routine laboratory arterial blood gas and co-oximetry values were obtained from 295 patients undergoing heart surgery during February 1 to September 30, 2010, and the values were assessed retrospectively. All samples with an arterial oxygen saturation value C90% were included (n = 1,421). The maximal change in Hb associated with hemodilution on cardiopulmonary bypass was determined within 48 hr of surgery (n = 180). A chart review was performed to determine the incidence of RBC transfusion and exogenous nitrate administration. All anonymous data were analyzed by linear regression to determine the relationship between Author contributions Gregory M.T. Hare designed the research, performed the research, contributed novel intellectual input, analyzed the data, and wrote the paper. Alexander Mu performed the research, contributed novel intellectual input, and analyzed the data. Alexander Romaschin designed the research, performed the research, contributed novel intellectual input, and analyzed the data. Nadine Shehata designed the research, performed the research, contributed novel intellectual input, and analyzed the data. W. Scott Beattie designed the research, performed the research, contributed novel intellectual input, analyzed the data, and wrote the paper. C. David Mazer designed the research, performed the research, contributed novel intellectual input, analyzed the data, and wrote the paper. Albert K.Y. Tsui contributed novel intellectual input, analyzed the data, and wrote the paper. RésuméObjectif La transfusion de globules rouges alloge´niques est l'un des principaux traitements de l'ane´mie aigues econdaire a`une perte sanguine et au remplissage liquidien en salle d'ope´ration. La de´cision de transfuser du sang repose essentiellement sur des marqueurs biologiques interme´diaires (he´moglobine, saturation en oxyge`ne du sang arte´riel, pression arte´rielle, fre´quence cardiaque) qui pourraient ne pas refle´ter avec pre´cision l'insuffisance d'apport d'oxyge`ne aux tissus. A`partir d'e´tudes expe´rimentales nous avons fait l'hypothe`se qu'une hypoxie tissulaire induite par l'ane´mie act...

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Section: Discussionmentioning

confidence: 84%

“…Methylene blue is used to treat methemoglobinemia by its ability to reduce MetHb via non-enzymatic donation of electrons 40 and by its ability to impair NO-mediated oxidation of hemoglobin. 3 Methylene blue is also known for its NO binding capacity and treatment of vasoplegia associated with cardiopulmonary bypass.…”

Section: Discussionmentioning

confidence: 99%

Plasma methemoglobin as a potential biomarker of anemic stress in humans

Hare

Romaschin

et al. 2012

Can J Anesth/J Can Anesth

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“…In our daily practice during the 15 years account for the observations included in this text, we have sought a causal relationship, and various aspects were considered: 1) the majority of cases occurred during or after CPB, 2) in the past, there were several cases associated with curare aloferine use during anesthesia induction, 3) some, more attenuated, cases occurred during anesthetical induction with standardized technique withetomidate, fentanyl, and pavulon diazepine, 4) some cases were clearly associated with the use of protamine, 5) in some cases we had the impression that vasodilation occurred after heparin use, 6) vasoplegic syndrome in non-cardiac surgeries was observed, 7) It seems that the cases occur in outbreaks, suggesting a relationship with drug lots, 8) there is no relation with the type of heart surgery, 9) many patients are diabetics, and 10) many patients had previously used the calcium antagonist diltiazem [19].…”

Section: Discussionmentioning

confidence: 99%

Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties

Évora¹,

Ribeiro

Vicente³

et al. 2009

Rev Bras Cir Cardiovasc

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Azul de metileno no tratamento da síndrome vasoplégica em cirurgia cardíaca. Quinze anos de perguntas, respostas, dúvidas e certezasMethylene blue for vasoplegic syndrome treatment in heart surgery. Fifteen years of questions, answers, doubts and certainties AbstractObjective: There is strong evidence that methylene blue (MB), an inhibitor of guanylate cyclase, is an excellent therapeutic option for vasoplegic syndrome (VS) treatment in heart surgery. The aim of this article is to review the MB's therapeutic function in the vasoplegic syndrome treatment.Methods: Fifteen years of literature review.Results: 1) Heparin and ACE inhibitors are risk factors; 2) In the recommended doses it is safe (the lethal dose is 40 mg/ kg); 3) The use of MB does not cause endothelial dysfunction; 4) The MB effect appears in cases of nitric oxide (NO) upregulation; 5) MB is not a vasoconstrictor, by blocking of the GMPc system it releases the AMPc system, facilitating the norepinephrine vasoconstrictor effect; 6) The most used dosage is 2 mg/kg as IV bolus followed by the same continuous infusion because plasmatic concentrations strongly decays in the first 40 minutes; 7) There is a possible "window of opportunity" for the MB's effectiveness.Conclusions: Although there are no definitive multicentric studies, the MB used to treat heart surgery VS, at the present time, is the best, safest and cheapest option, being a Brazilian contribution for the heart surgery.

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“…Based on several studies showing the safety and efficacy of the low dose of MB solution in systemic and epidural administration, 13,22,32,49 we designed this randomized, placebo-controlled, triple-blind study to evaluate the effect of MB on postoperative LBP and radicular pain and quality of life (QOL) in patients with lumbar discectomy.…”

mentioning

confidence: 99%

Effects of methylene blue on postoperative low-back pain and functional outcomes after lumbar open discectomy: a triple-blind, randomized placebo-controlled trial

Farrokhi¹,

Lotfi

Masoudi³

et al. 2016

SPI

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OBJECT Despite advances in surgical and anesthesiology techniques, many patients continue to experience postoperative pain after lumbar disc operations. This study aims to investigate the effects of methylene blue (MB) on preventing postoperative low-back pain (LBP) with or without radicular pain and improving the quality of life (QOL) in patients undergoing lumbar open discectomy. METHODS This is a prospective, randomized, triple-blind, placebo-controlled clinical trial, which was conducted at Shiraz University of Medical Sciences between July 2011 to January 2012. Of a total of 130 patients, 115 were eligible for participation; 56 received 1 ml of MB solution at a concentration of 0.5% (MB group) and 59 received an equivalent volume of normal saline (control group). Primary outcomes were the control of LBP with or without radicular pain, which was evaluated preoperatively and at 24 hours and 3 months after surgery with the use of a visual analog scale (VAS), and the improvement of QOL, which was assessed preoperatively and 3 months postoperatively by means of the Persian translation of the Oswestry Disability Index questionnaire. RESULTS The mean VAS scores for LBP were significantly lower in the MB group compared with the control group at 24 hours (1.25 ± 0.97 vs 2.80 ± 0.69, p < 0.001) and 3 months (1.02 ± 1.29 vs 2.07 ± 1.10, p = 0.019) after treatment. The mean radicular pain scores decreased significantly in the 2 groups at 24 hours after surgery, but the mean radicular pain score was significantly lower in the MB-treated patients than the control group. However, the difference between radicular pain scores in the MB group (1 ± 1.1) and the control group (1.2 ± 1) was not statistically significant (p = 0.64). The reduction in LBP was greater in the MB group than the control group (8.11 ± 1.74 vs 6.07 ± 1.52, p = 0.023, CI 95% −1.37 to −0.10). The functional QOL improved significantly 3 months after the operation in both groups (p < 0.001). Moderate disability occurred more frequently in the control group than in the MB group (14.5% vs 7.7%, p = 0.004). No toxicity, adverse effects, or complications were found in the group of patients treated with MB injection. CONCLUSIONS A single dose of MB (1 ml 0.5%) for coating the dura and surrounding tissues (facet and muscle) shows promising results in terms of safety, reduction of postoperative pain, and functional outcome compared with placebo.

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Methylene Blue and Vasoplegia: Who, When, and How?

Cited by 44 publications

References 2 publications

Plasma methemoglobin as a potential biomarker of anemic stress in humans

Plasma methemoglobin as a potential biomarker of anemic stress in humans

Methylene blue for vasoplegic syndrome treatment in heart surgery: fifteen years of questions, answers, doubts and certainties

Effects of methylene blue on postoperative low-back pain and functional outcomes after lumbar open discectomy: a triple-blind, randomized placebo-controlled trial

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