IV Methylene blue post OHS vasoplegia

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Just curious if anyone has given IV Methylene blue post cardiopulmonary bypass for catecholamine-refractory vasoplegia.

The only knowledge I had of methylene blue was the antagonist to cynanide poisoning.

I thought it was interesting...and thought I share it with you.

Please give me some feedback!

This patient presented in a ER c/o CP, IABP placed in cath lab was flown to our facility. A LVAD was placed to come off pump. When I received and attempted to recover this patient, he was on: :redbeathe

Nitric oxide 40ppm

Norepi- 0.35mcg/kg/min, Epi- 0.2 mcg/min, Vaso 0.1 units/min, Dopa 10mcg/kg/min, Neo-200mcg/min, Milrinone 0.5mcg/kg/min.

Blood pressure 80-90s, sometimes dropping in the 60-70s.

CO/CI was normal, hyperdynamic. SVR--580, SVO2- 68%

Asystolic underlying the temp pacer.

These numbers are after I volume resuscitated the patient.

A stat TEE was ordered, because the pt was an open chest...EF was calculated @ 5 (FIVE) %

Anyways...as a last ditch effort the surgeon ordered methylene blue 1.5mg/kg over 30mins. Apparently, in Europe it is used often for patients who exhibit postoperative vasoplegic syndrome: hypotension, low filling pressures, high/normal CI, low periphereal resistance and high vasopressor requirements. In some cases, vasoplegia is refractory to norepinephrine...and that is why they use methylene blue.

I ran the methylene blue a little slower b/c I was told the BP will drop initially. It did!!

However, within 4 hours the vasoactive gtts were cut in half!! :yeah:

The patient is still sick..he took a hit to the kidneys and liver. CRRT was initiated the first night. I wouldnt be surprised if he took a hit to the head too. :uhoh21:

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Specializes in CTICU.

Haven't heard of it. Which VAD is he on?

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Abiomed AB5000

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Specializes in CTICU.

Ugh....

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Specializes in DNAP Student.
Just curious if anyone has given IV Methylene blue post cardiopulmonary bypass for catecholamine-refractory vasoplegia.

The only knowledge I had of methylene blue was the antagonist to cynanide poisoning.

I thought it was interesting...and thought I share it with you.

Please give me some feedback!

This patient presented in a ER c/o CP, IABP placed in cath lab was flown to our facility. A LVAD was placed to come off pump. When I received and attempted to recover this patient, he was on: :redbeathe

Nitric oxide 40ppm

Norepi- 0.35mcg/kg/min, Epi- 0.2 mcg/min, Vaso 0.1 units/min, Dopa 10mcg/kg/min, Neo-200mcg/min, Milrinone 0.5mcg/kg/min.

Blood pressure 80-90s, sometimes dropping in the 60-70s.

CO/CI was normal, hyperdynamic. SVR--580, SVO2- 68%

Asystolic underlying the temp pacer.

These numbers are after I volume resuscitated the patient.

A stat TEE was ordered, because the pt was an open chest...EF was calculated @ 5 (FIVE) %

Anyways...as a last ditch effort the surgeon ordered methylene blue 1.5mg/kg over 30mins. Apparently, in Europe it is used often for patients who exhibit postoperative vasoplegic syndrome: hypotension, low filling pressures, high/normal CI, low periphereal resistance and high vasopressor requirements. In some cases, vasoplegia is refractory to norepinephrine...and that is why they use methylene blue.

I ran the methylene blue a little slower b/c I was told the BP will drop initially. It did!!

However, within 4 hours the vasoactive gtts were cut in half!! :yeah:

The patient is still sick..he took a hit to the kidneys and liver. CRRT was initiated the first night. I wouldnt be surprised if he took a hit to the head too. :uhoh21:

Yes, it is a common intervention for a vasopressor refractory hyotension mostly seen in induction during coronary artery bypass. Many studies in the past decades concluded the effectiveness of the agent and the post operative course has been significant.

Although a variety of mechanisms have been proposed to explain how methylene blue achieves vasopressor effects, it is now widely accepted that the major pathway in the adrenergic response is due to the blockade of nitric oxide. Nitric oxide is released in the endothelium and activates guanylyl cyclase which increases cGMP intracellularly causing relaxtion and vosodilation.

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It is also very useful in vasopressor refractory hypotension in septic shock.

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Specializes in ICU/CVICU.

sounds like a protamine reaction that i have seen in the past, interesting that the epi was at just 0.2 mcg/ min, could have gone up to 10 eh>? and the vasso could be at 0.4.. interesting though

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

we've used it for cathecholamine refractory vasoplegia on our cardiac surgery patients but very rarely. i only remember 2 cases and they were not lvad implantations. there is quite a bit of literature out there on its use in cardiac surgery and i wish i could post the full text of the articles i found but here's the references if you have time to look them up:

vasoplegic syndrome - the role of methylene blue. european journal of cardio-thoracic surgery, volume 28, issue 5, november 2005, pages 705-710. ganesh shanmugam

use of methylene blue for catecholamine-refractory vasoplegia from protamine and aprotinin. the annals of thoracic surgery, volume 87, issue 2, february 2009, pages 640-642. danny del duca md, shashank s. sheth md, ann e. clarke md, kevin j. lachapelle md and patrick l. ergina md

methylene blue as drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass. journal of thoracic and cardiovascular surgery, volume 127, issue 3, march 2004, pages 895-896, paulo roberto b. evora, ricardo l. levin

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We just used this on a patient the other night. And sure enough, we went way down on the pressors fairly quickly. Does anyone have a policy/protocol for given methylene blue?

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