1252: BLUE, INSIDE AND OUT: METHYLENE BLUE AS THE RESCUE THERAPY FOR REFRACTORY DISTRIBUTIVE SHOCK

Abstract

Introduction: Calcium channel blocker (CCB) overdose is frequent in the US. Recommendations for treatment were last published in Critical Care Medicine in 2017. Treatment algorithms address hypotension, myocardial dysfunction, and bradycardia. Treatment, in addition to vasopressor support, often includes unique modalities such as glucagon, high-dose insulin, and lipid emulsion. Often, these overdoses are accompanied by additional anti-hypertensives making management challenging. Here we present such a case in which hypotension seemed to persist despite extremely high vasopressor requirements. Description: A 54 year old male attempted suicide by ingesting amlodipine, valsartan, hydrochlorothiazide, and cyclobenzaprine. Soon the patient was on 5 high dose vasopressors: norepinephrine at 200 mcg/min, epinephrine at 200 mcg/min, angiotensin 2 at 40 ng/kg/min, vasopressin at 2.4 units/hour, and phenylephrine at 200 mcg/min. Poison control recommended against use of high-dose insulin and lipid emulsion because TTE showed normal contractility, and there was no evidence of bradycardia. VA-ECMO consult was placed, but again due to normal myocardial function, patient was determined to not be a good candidate. As a last resort, methylene blue (MB) was trialed. Patient’s blood pressure showed improvement within 1 hour of bolus administration. He was continued on MB infusion for 1 day in addition to 5 other vasopressors. The only side effect observed was blue skin discoloration which resolved by discharge. Subsequently, our patient was able to be liberated from all the infusions in 4.5 days. Discussion: We present a case of a polypharmacy overdose including both a CCB and angiotensin receptor blocker. Rescue therapies often used in CCB overdose were recommended against by Poison Control due to the absence of myocardial dysfunction and bradycardia. MB was chosen as there seemed to be no alternative for patient’s vasoplegia. MB inhibits nitric oxide synthase and guanylate cyclase which decreases the amount of vasodilating nitric oxide and cyclic guanosine monophosphate. No recommendations regarding the use of MB are in the 2017 Experts Consensus Recommendations for the Management of CCB Poisoning in Adults, however, there is growing evidence that MB should be in the algorithm of rescue therapies in CCB overdose.