SummaryVasodilatory shock after cardiopulmonary bypass is a common complication requiring treatment with high doses of inotropes and prolonged stays in the intensive care unit. The vasodilatory shock is initiated by an inflammatory response to the extracorporeal circuit. The inflammatory response results in endothelial synthesis and release of nitric oxide resembling the clinical features observed in vasodilatory shock caused by septicaemia. During vasodilatory shock, the inhibition of nitric oxide synthase and the nitric oxide ⁄ cyclic guanylyl monophosphate pathway is an attractive adjunct to therapy with traditional inotropes. Methylthioninium chloride inhibits nitric oxide ⁄ cyclic guanylyl monophosphate mediated vasodilation and can successfully be used as a supplement in the treatment of vasodilatory shock associated with cardiopulmonary bypass. The application of methylthioninium chloride in septicaemia has not produced comparable positive clinical results. During the last decade, many reports and more letters but few studies have commented on clinical experience with methylthioninium chloride (MB), formerly known as methylene blue, in the treatment of vasodilatory shock during and after surgery requiring cardiopulmonary bypass (CPB). Peri-operative vasodilatory shock accompanied by tachycardia and increased cardiac output has, in the absence of other causes of hypotension, been termed vasoplegic syndrome [1] or low systemic vascular resistance syndrome [2]. It is widely recognised that these features are the results of CPB initiating an inflammatory response clinically indistinguishable from that observed in septicaemia [3]. A result of the CPB-associated inflammatory response is an increased endothelial production and release of nitric oxide (NO), causing profound hypotension. Methylthioninium chloride, being a potent inhibitor of NO-mediated vasodilation, offers an attractive proposition as an adjunct in the treatment of vasodilatory shock. These characteristics of MB have been reported in many observational studies and case reports. However, no reports have concurrently reviewed the pharmacology and clinical applications of MB in the treatment of vasoplegic syndrome. Therefore, the aim of this review is to summarise the current knowledge and application of MB with special emphasis on vasodilatory shock associated with CPB.