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METHYLENE BLUE IN REFRACTORY SEPTIC SHOCK
Chest ; 158(4):A2558, 2020.
Article in English | EMBASE | ID: covidwho-871911
ABSTRACT
SESSION TITLE Medical Student/Resident Critical Care Posters SESSION TYPE Med Student/Res Case Rep Postr PRESENTED ON October 18-21, 2020

INTRODUCTION:

Refractory septic shock is characterized by persistent hypotension with end-organ damage due to an underlying infection that fails to respond to maximal vasopressor support. Beyond IV fluids and antibiotics, treatment options are limited. Here, we present a case of refractory septic shock that rapidly improved following methylene blue (MB) administration. CASE PRESENTATION An 82-year-old man with a past medical history of coronary artery disease presented to the hospital with one week of altered mental status and dyspnea. He was tachycardic to 159 bpm, hypotensive to 64/41 mmHg, and tachypneic. Bloodwork revealed mild leukopenia, acute kidney injury, and severe metabolic acidosis with pH 7.15 and lactate 10.7 mmol/L. A nasopharyngeal swab for SARS-CoV-2 was positive. Urinalysis was concerning for infection. CT chest showed bilateral patchy airspace opacities consistent with multifocal pneumonia. The patient was intubated for airway protection and administered IV fluids, piperacillin-tazobactam, and vancomycin. Despite aggressive fluid resuscitation, he remained persistently hypotensive, necessitating maximum dosages of norepinephrine, vasopressin, epinephrine, and phenylephrine infusions. Point-of-care ultrasound revealed preserved cardiac function. The decision was made to administer MB at 1 mg/kg over one hour. Within 3 hours, epinephrine infusion was successfully weaned off. Phenylephrine infusion was discontinued 24 hours later. Vasopressin and norepinephrine infusions were successfully stopped by hospital day 4 and 6, respectively, and patient's shock had resolved. Urine culture grew Escherichia coli. Antibiotic regimen was narrowed to ceftriaxone. The patient was extubated on hospital day 6 and was discharged home on hospital day 13.

DISCUSSION:

In septic shock, uncontrolled cytokine and nitric oxide (NO) lead to loss of vascular tone, which results in inadequate tissue oxygenation and end-organ damage. MB inhibits guanylate cyclase, which is a second messenger in NO-mediated vasodilatation. Several studies have noted a decrease in vasopressor requirements and preservation of cardiac performance markers (such as left and right ventricular stroke work index) when comparing MB to placebo in refractory septic shock;however, current literature does not suggest a reduction in mortality or length of hospital stay. Pulmonary vasoconstriction resulting in hypoxia was the most serious adverse effect, but was only noted with higher MB dosing (3-4 mg/kg). This case supports the previously described beneficial effects of MB and suggests that further trials should be conducted to assess the effect of MB on clinical outcomes.

CONCLUSIONS:

This case highlights the potential role of MB in refractory septic shock. Its use is considered safe when administered in low doses. Reference #1 Mayer B, Brunner F, Schmidt K. Inhibition of nitric oxide synthesis by methylene blue. Biochem Pharmacol 1993;45 367–74 Reference #2 Kirov MY, Evgenov OV, Evgenov NV, et al. Infusion of methylene blue in human septic shock a pilot, randomized, controlled study. Crit Care Med 2001;291860–7. Reference #3 Memis D, Karamanlioglu B, Yuksel M, et al. The influence of methylene blue infusion on cytokine levels during severe sepsis. Anaesth Intensive Care 2002;30755–62. DISCLOSURES No relevant relationships by Mouhanned Eliliwi, source=Web Response No relevant relationships by Eliot Friedman, source=Web Response No relevant relationships by Stephanie Hart, source=Web Response No relevant relationships by Jennifer Meyfeldt, source=Web Response

Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: Chest Year: 2020 Document Type: Article

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Full text: Available Collection: Databases of international organizations Database: EMBASE Language: English Journal: Chest Year: 2020 Document Type: Article