Reversal of refractory hypotension with single-dose methylene blue after coronary artery bypass surgery

Abstract

Low systemic vascular resistance (SVR) requiring vasoconstrictor therapy is a recognized complication of cardiopulmonary bypass. We present here a case in which norepinephrine therapy had failed and alternative strategy with a guanylate cyclase inhibitor, methylene blue, was instituted, resulting in a rapid, permanent restoration of hemodynamic stability.Clinical summary. A 72-year-old man with 3-vessel disease and moderate left ventricular function was admitted for coronary artery bypass surgery. Coronary risk factors included hypercholesterolemia, hypertension, prior smoking, and a family history of heart disease. He was on a program of amlodipine, atenolol, enalapril, simvastatin, and aspirin. Medical history included a cerebrovascular accident. His blood pressure was 150/90 mm Hg and he had atrial fibrillation with a pulse rate of 60 beats/min. Baseline blood results were normal apart from a borderline serum creatinine value of 105 µmol/L.Coronary artery bypass grafting was performed under normothermic conditions with intermittent crossclamp fibrillation. The operation was uneventful and total bypass time was 67 minutes. He was transferred to the intensive care unit receiving intravenous glyceryl trinitrate (2 mL/h) and cardiac dopamine (10.9 µg/kg per minute). Four hours after the operation, his blood pressure progressively sagged. The central venous pressure was 10 mm Hg and the hemoglobin level was 8.9 g/dL after a total of 2.5 L of colloid and 1 unit of blood. Blood loss was negligible and oxygen tension was From the

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

“…Observing the other 55 studies we can find: 1) one study (1.67%) based on evidences through metanalysis of literature [13]; 2) seven review articles (11.67%) [4,14,23]. The other bibliographical citations in number of 44 (73.33%) are distributed as case reports (great majority) [24][25][26][27][28][29][30][31][32][33][34][35][36], letters [37][38][39][40][41][42][43][44], technical aspects of the MB use [45][46][47][48][49][50] and other studies involving risk [51,52], the VS incidence in the "off pump" CABG and the possibility of MB use in anaphylaxis and anaphylactic shock [53], also a proposal of the author of this text ( Figure 4) [54][55][56][57][58]. The presented numbers, surely, are not totally compatible with the total of publications, but it is possible to assume that this imprecision does not affect the general vision of the problem.…”

“…From these concepts a certainty emanates, that is: the VS is a consequence of systemic inflammatory reaction, being, therefore, an endothelial vasoplegic dysfunction [37].…”

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

“…Invasive hemodynamic data is well documented in cases of refractory vasodilatory shock treated with methylene blue in sepsis and coronary artery bypass surgery [4,5,7]. However, these are not well documented in previous cases of refractory vasodilatory shock treated with methylene blue.…”

“…Increases in systemic vascular resistance and mean arterial pressure have been consistently described following methylene blue administration for shock due to non-poisoning causes, including vasoplegic syndrome after coronary artery bypass surgery [4] and sepsis [5][6][7]. Methylene blue, from a mechanistic standpoint, is an attractive therapy for drug-induced vasodilatory shock, though published literature includes only a small number of human case reports and animal studies [8][9][10][11].…”

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery

“…There were no sufficient data on the effectiveness that allow definitive conclusions regarding the use of antifibrinolytic agents in other situations. 61,62,63,64,65,66,67 While other review reports that aminocaproic acid and tranexamic acid are safe, it is noteworthy that the works included were smaller than the jobs studied aprotinin. Therefore, the authors say, the safety data are not reliable, especially with regard to thrombosis.…”