Prolonged methylene blue infusion in refractory septic shock: a case report

Abstract

Purpose Methylene blue (MB) has been advocated for the treatment of refractory hemodynamic instability in patients with septic shock. However, the use of MB infusions in septic shock is not considered standard treatment, and the available literature describes infusions of short duration, typically less than six hours. Clinical features We report a case of septic shock in a 67-yr-old male who required maximal vasopressor support with norepinephrine, epinephrine, and vasopressin. Despite standard protocols for the treatment of septic shock, the patient's hemodynamic status was refractory 80 hr post admission. However, initiation of a MB infusion resulted in the rapid restoration of hemodynamic stability and a subsequent decrease in vasopressor requirements.Multiple attempts to discontinue the MB infusion resulted in immediate and repeated increases in vasopressor requirements, necessitating a continuous infusion with a slow taper of MB for 120 hr. Ultimately, the patient survived the illness and was discharged home. We observed no adverse events that could be attributed to the use of MB. Conclusion In our patient, the use of MB resulted in hemodynamic stability unattained with standard vasopressor support. Further research is warranted on the use of MB in patients with septic shock. RésuméObjectif Le bleu de me´thyle`ne (BM) a e´te´propose´par certains chercheurs comme traitement de l'instabiliteh e´modynamique re´fractaire chez les patients en choc septique. La perfusion de BM n'est toutefois pas conside´re´e comme un traitement standard du choc septique, et la litte´rature publie´e de´crit des perfusions de courte dure´e, en ge´ne´ral de moins de six heures. É léments cliniques Nous rapportons un cas de choc septique chez un homme de 67 ans qui a eu besoin d'un soutien vasopresseur maximal avec de la nore´pine´phrine, de l'e´pine´phrine et de la vasopressine. Malgre´l'application des protocoles normalise´s pour le traitement du choc septique, l'e´tat he´modynamique du patient demeurait re´fractaire 80 h apre`s son admission. L'amorce d'une perfusion de BM a toutefois permis de re´tablir rapidement la stabilite´he´modynamique du patient et a entraıˆne´une re´duction subse´quente de ses besoins en vasopresseurs. Les nombreuses tentatives d'interruption de la perfusion de BM ont entraıˆne´des augmentations imme´diates et re´pe´te´es des besoins en vasopresseurs, c'est pourquoi une perfusion continue a`un de´bit plus bas de BM durant 120 h a e´te´mise en place. Le patient a finalement surve´cu a`la maladie et reçu son conge´de l'hôpital. Nous

Methylene Blue for Distributive Shock: A Potential New Use of an Old Antidote

“…There are multiple experimental models of septic shock that support the use of methylene blue in the treatment of refractory distributive shock [70][71][72][73][74][75][76]. The majority of clinical data on the use of methylene blue for such therapy is observational with case reports and small observational studies, but there are also small controlled clinical trials [77][78][79][80][81][82]. The majority of these studies demonstrate an increase in mean arterial pressure and/or decrease in pressor requirement.…”

Effect of methylene blue on hemodynamic and metabolic response in septic shock patients

“…[21][22][23][24] Methylene blue is widely used for reversal of vasoplegia in the postoperative period of major surgeries with excellent results. [25][26][27][28][29] Our primary aim with this protocol is to identify whether methylene blue can become an effective, cheap and easily accessible alternative to treat septic shock in association with the conventional treatment currently used. Our hypothesis is that methylene blue may contribute to reducing vasopressor infusion, reversing refractory vasodilatation, improve hemodynamic and tissue perfusion, delay nitric oxideinduced mitochondrial death, besides being a low-cost medication, few side effects and easily accessible in all health units.…”

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

“…Two randomized controlled trials evaluated the use of MB in treating hypotension secondary to septic shock [27,28]. In both studies, as well as in observational ones and case reports [29][30][31][32][33][34][35], MB was able to cause a statistically significant increase of MAP (see Table 2 for details of included studies). MB led to significant increases in systemic vascular resistance [29,31,32].…”

“…A recent meta-analysis shows that MB blue could significantly increase MAP in patients with refractory hypotension caused by vascular paralysis during the course of vasodilatory shock and decrease the lactate levels [36]. Administration of MB was able to facilitate the weaning of catecholamine vasopressors as well [28,31,35]. However, the MB doses administered and concomitant vasopressor titration parameters were inconsistent among all studies.…”

“…Administration of MB was able to facilitate the weaning of catecholamine vasopressors as well [ 28 , 31 , 35 ].…”