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Use of methylene blue in the treatment of refractory vasodilatory shock after cardiac assist device implantation: report of four consecutive cases.

Michel S, Weis F, Sodian R, Beiras-Fernandez A, Bigdeli AK, Kaczmarek I, Bruegger D - J Clin Med Res (2012)

Bottom Line: This complication is often associated with high mortality, especially if refractory to conventional vasoconstrictor treatment.In all patients, administration of a single dose of methylene blue (2 mg/kg body weight) resulted in an immediate and persistent decrease in vasoconstrictor dosages and serum lactate concentrations.Despite of this benefit, all patients deceased during hospital stay, however, this was not related to the methylene blue treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiac Surgery, Ludwig-Maximilians-University, Munich, Germany.

ABSTRACT
Vasodilatory shock frequently occurs after cardiac surgery, particularly after cardiac assist device implantation. This complication is often associated with high mortality, especially if refractory to conventional vasoconstrictor treatment. Methylene blue, a guanylate cyclase inhibitor, has been successfully used in the management of vasodilatory shock associated with cardiopulmonary bypass. We present four successive cases after implantation of cardiac assist devices suffering from norepinephrine and vasopressin refractory severe vasodilatory shock. In all patients, administration of a single dose of methylene blue (2 mg/kg body weight) resulted in an immediate and persistent decrease in vasoconstrictor dosages and serum lactate concentrations. Despite of this benefit, all patients deceased during hospital stay, however, this was not related to the methylene blue treatment. Methylene blue seems to be a promising therapeutical option in patients with otherwise resistant vasodilatory shock after cardiac assist device implantation. However, controlled clinical trials are necessary to substantiate safety and efficacy.

No MeSH data available.


Related in: MedlinePlus

Individual and median values of mean arterial blood pressure (panel A), norepinephrine dosage (panel B), vasopressin dosage (panel C), and serum lactate concentration (panel D) before (B) and 1, 2, 3, 4, 5, 12, and 24 hours after a single dose administration of methylene blue (2 mg/kg body weight).
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Figure 1: Individual and median values of mean arterial blood pressure (panel A), norepinephrine dosage (panel B), vasopressin dosage (panel C), and serum lactate concentration (panel D) before (B) and 1, 2, 3, 4, 5, 12, and 24 hours after a single dose administration of methylene blue (2 mg/kg body weight).

Mentions: A 49-year-old male patient (188 cm, 98 kg) suffered from decompensated dilative cardiomyopathy. As he did not respond to conventional treatment (inotropes and insertion of an intraaortic balloon pump) a Jarvik 2000 left ventricular assist device (Jarvik Heart Inc., NYC, NY, USA) was implanted. Postoperatively, the patient developed right heart failure, necessitating the implantation of an additional temporary right ventricular assist device (Levitronix, Levitronix GmbH, Zurich, Switzerland). Severe postoperative bleeding required rethoracotomy and mass transfusion. Despite no further bleeding and faultless function of both cardiac assist devices, the patient developed a severe vasoplegic shock, requiring very high dosages of norepinephrine (4.0 mg/h) and vasopressin (6.0 I.U./h). After administration of a single dose methylene blue both norepinephrine and vasopressin dosages rapidly decreased and serum lactate concentrations normalized (Fig. 1). On the fourth postoperative day the patient developed pneumonia caused by pseudomonas aeruginosa with severe impairment of pulmonary function. An oxygenator was connected to the right ventricular assist device to enable sufficient oxygenation. Despite inhalative application of milrinone and iloprost, right ventricular function did not recover sufficiently. Although the patient was treated with antibiotics (piperacillin/tazobactam, ciprofloxacin, vancomycin) markers of infection did not decrease and the patient died ten days after methylene blue administration from multi-organ failure.


Use of methylene blue in the treatment of refractory vasodilatory shock after cardiac assist device implantation: report of four consecutive cases.

Michel S, Weis F, Sodian R, Beiras-Fernandez A, Bigdeli AK, Kaczmarek I, Bruegger D - J Clin Med Res (2012)

Individual and median values of mean arterial blood pressure (panel A), norepinephrine dosage (panel B), vasopressin dosage (panel C), and serum lactate concentration (panel D) before (B) and 1, 2, 3, 4, 5, 12, and 24 hours after a single dose administration of methylene blue (2 mg/kg body weight).
© Copyright Policy - open access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3376881&req=5

Figure 1: Individual and median values of mean arterial blood pressure (panel A), norepinephrine dosage (panel B), vasopressin dosage (panel C), and serum lactate concentration (panel D) before (B) and 1, 2, 3, 4, 5, 12, and 24 hours after a single dose administration of methylene blue (2 mg/kg body weight).
Mentions: A 49-year-old male patient (188 cm, 98 kg) suffered from decompensated dilative cardiomyopathy. As he did not respond to conventional treatment (inotropes and insertion of an intraaortic balloon pump) a Jarvik 2000 left ventricular assist device (Jarvik Heart Inc., NYC, NY, USA) was implanted. Postoperatively, the patient developed right heart failure, necessitating the implantation of an additional temporary right ventricular assist device (Levitronix, Levitronix GmbH, Zurich, Switzerland). Severe postoperative bleeding required rethoracotomy and mass transfusion. Despite no further bleeding and faultless function of both cardiac assist devices, the patient developed a severe vasoplegic shock, requiring very high dosages of norepinephrine (4.0 mg/h) and vasopressin (6.0 I.U./h). After administration of a single dose methylene blue both norepinephrine and vasopressin dosages rapidly decreased and serum lactate concentrations normalized (Fig. 1). On the fourth postoperative day the patient developed pneumonia caused by pseudomonas aeruginosa with severe impairment of pulmonary function. An oxygenator was connected to the right ventricular assist device to enable sufficient oxygenation. Despite inhalative application of milrinone and iloprost, right ventricular function did not recover sufficiently. Although the patient was treated with antibiotics (piperacillin/tazobactam, ciprofloxacin, vancomycin) markers of infection did not decrease and the patient died ten days after methylene blue administration from multi-organ failure.

Bottom Line: This complication is often associated with high mortality, especially if refractory to conventional vasoconstrictor treatment.In all patients, administration of a single dose of methylene blue (2 mg/kg body weight) resulted in an immediate and persistent decrease in vasoconstrictor dosages and serum lactate concentrations.Despite of this benefit, all patients deceased during hospital stay, however, this was not related to the methylene blue treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiac Surgery, Ludwig-Maximilians-University, Munich, Germany.

ABSTRACT
Vasodilatory shock frequently occurs after cardiac surgery, particularly after cardiac assist device implantation. This complication is often associated with high mortality, especially if refractory to conventional vasoconstrictor treatment. Methylene blue, a guanylate cyclase inhibitor, has been successfully used in the management of vasodilatory shock associated with cardiopulmonary bypass. We present four successive cases after implantation of cardiac assist devices suffering from norepinephrine and vasopressin refractory severe vasodilatory shock. In all patients, administration of a single dose of methylene blue (2 mg/kg body weight) resulted in an immediate and persistent decrease in vasoconstrictor dosages and serum lactate concentrations. Despite of this benefit, all patients deceased during hospital stay, however, this was not related to the methylene blue treatment. Methylene blue seems to be a promising therapeutical option in patients with otherwise resistant vasodilatory shock after cardiac assist device implantation. However, controlled clinical trials are necessary to substantiate safety and efficacy.

No MeSH data available.


Related in: MedlinePlus