Abstract
Hemodynamic effectiveness of methylene blue (MB) was tested in patients with refractory distributive shock. A retrospective analysis of 20 critically-ill patients who developed refractory shock was performed. Patients were divided into two study groups as responders with positive hemodynamic response to MB administration (defined as 10% decrease of norepinephrine dose) and non-responders. Hemodynamic, outcome data and baseline tissue hypoxia-related parameters including ratio of central venous-to-arterial carbon dioxide tension to arterio-venous oxygen content (P(v-a)CO2/C(a-v)O2) were compared between the groups. There were 9 (45%) responders and 11 (55%) non-responders to single bolus of MB administration. Dose of MB did not differ between responders and non-responders (1.3 ± 0.5 vs. 1.3 ± 0.4 mg/kg respectively, P = 0.979). MB responders had lower baseline P(v-a) CO2/C(a-v)O2 (1.79 ± 0.73 vs. 3.24 ± 1.18, P = 0.007), higher pH (7.26 ± 0.11 vs. 7.16 ± 0.10, P = 0.037) and lower lactate levels at 12 hours post MB administration (3.4 ± 2.7 vs. 9.9 ± 2.2 mmol/L, P = 0.002) compared to non-responders. Methylene blue represents a non-adrenergic vasopressor with only limited effectiveness in patients with refractory distributive shock. Profound tissue hypoxia with high degree of anaerobic metabolism was associated with the loss of hemodynamic responsiveness to its administration.
Highlights
Hemodynamic effectiveness of methylene blue (MB) was tested in patients with refractory distributive shock
Our study showed limited hemodynamic responsiveness to MB administration of 45% in patients with refractory distributive shock
Non-responders were in a more profound state of tissue hypoxia documented by significant metabolic acidosis and higher P(v-a)CO2/C(a-v)O2 compared to responders
Summary
Hemodynamic effectiveness of methylene blue (MB) was tested in patients with refractory distributive shock. New rescue methods have been introduced in the management of refractory shock including the use of low-dose corticosteroid supplementation and non-adrenergic vasopressors administration such as vasopressin, angiotensin II and methylene blue[4,5]. To the other non-adrenergic vasopressors, there is a lack of data on the actual MB hemodynamic responsiveness in patients with already established refractory shock and the factors that may influence it. In this retrospective study, we evaluated the hemodynamic effectiveness of MB in the treatment of refractory distributive shock and its impact on clinical outcomes in a mixed population of medical and surgical patients
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