Successful use of methylene blue for catecholamine-refractory vasoplegic shock due to metformin intoxication: A case report and literature review.

Background: Severe metformin intoxication can lead to lactic acidosis and vasoplegic shock, for which the optimal management strategy remains uncertain, especially in cases of severe circulatory collapse. Case Presentation: A 45-year-old diabetic woman on metformin therapy presented with impaired consciousness and seizures. She had experienced a cardiac arrest and undergone extracorporeal cardiopulmonary resuscitation. Blood gas analysis showed severe lactic acidosis. A 71-g metformin packet was found at the patient's home, suggesting an overdose. Despite extracorporeal support and blood purification, severe lactic acidosis and hypotension persisted. Methylene blue was administered 32 h from the onset, which improved her metabolic and circulatory status. We examined her blood sample throughout the case to check the transition of metformin blood concentration. Conclusion: Methylene blue may be beneficial for severe metformin toxicity, regardless of the blood concentration of metformin and the time since intoxication. However, further research is needed to establish its optimal use and effectiveness.

Impact of oligomeric enteral nutrition with low-molecular-weight whey peptides on diarrhea in critical care nutrition.

Diarrhea is one of the most common complications associated with enteral nutrition in hospitalized patients. Oligomeric enteral nutrition has been considered to reduce the incidence of diarrhea. We herein introduced and examined the effects of a specific oligomeric enteral nutrition with the low-molecular-weight whey peptides, Peptino|® in critically ill patients with refractory diarrhea or at high risk of mesenteric ischemia. A retrospective study of a consecutive case series was conducted. Patients were divided into two groups: enteral nutrition products were switched to Peptino|® (switching group) and Peptino|® was the initial enteral nutrition product (first initiation group). Sixty-eight patients were administered Peptino|® in the ICU. Diarrhea occurred in 28.3% of patients in the switching group and 13.3% in the first initiation group. EN failure with gastrointestinal intolerance was observed in 6 patients (8.8%). Diarrhea resolved in 29 out of the 35 patients (82.9%) with diarrhea prior to the switch to Peptino|®. Diarrhea cessation within 24 h of the initiation of Peptino|® was achieved in 11 patients (31.4%) and within 24-48 h in 12 (34.3%). Mesenteric ischemia was not detected in any patients. In conclusion, Peptino|® may be effective against diarrhea and gastrointestinal intolerance in critical care nutrition.