Objectives: cardiopulmonary bypass (CPB) can be complicated by vasoplegia that is refractory to vasopressors. Methylene blue (MB) represents an alternative in such cases.
Patients and Methods: Retrospective observational historical control-matched study. From 2010 to 2015, all patients who received MB for vasoplegia post-CPB were included in this study. Historical controls from the period of 2004 to 2009 were matched. End-points were the time till improvement of vasoplegia (Ti), 30-day mortality, cardiac surgical Intensive Care Unit (CSICU) morbidity, and length of stay (LOS).
Results: Twenty-eight patients were matched in both groups. There were no statistically significant differences between the two groups in demographic, laboratory data on admission, or hemodynamic profile before use of MB. Ti and time to complete discontinuation of vasopressors were statistically significant less in MB group (8.2 ± 2.6 vs. 29.7 ± 6.4, P = 0.00 and 22.6 ± 5.2 vs. 55.3 ± 9.4, P = 0.00) respectively. Mortality at day 30 was significantly higher in controls compared to MB (1 patient [3.6%] vs. 6 patients [21.4%], long rank P = 0.04). CSICU, hospital LOS, and incidence of renal failure was significantly higher in control group (12.4 ± 3.7 vs. 7 ± 1.4, P = 0.03), (19.5 ± 2.4 vs. 10.9 ± 3.2, P = 0.05) and (9 patients [32.1%] vs. 2 patients [7.1%], P = 0.04), respectively. Duration of mechanical ventilation was less in MB patients; however, did not reach statistical significance.
Conclusions: the use of MB for vasoplegia postcardiac surgery was associated with rapid recovery of hemodynamics, shorter need for vasopressors, less ICU mortality, less incidence of renal failure, and shorter LOS.
Gomes WJ, Carvalho AC, Palma JH, Gonçalves I Jr., Buffolo E. Vasoplegic syndrome: A new dilemma. J Thorac Cardiovasc Surg 1994;107:942-3.
Fischer GW, Levin MA. Vasoplegia during cardiac surgery: Current concepts and management. Semin Thorac Cardiovasc Surg 2010;22:140-4.
Evora PR. Should methylene blue be the drug of choice to treat vasoplegias caused by cardiopulmonary bypass and anaphylactic shock? J Thorac Cardiovasc Surg 2000;119:632-4.
Evora PR, Levin RL. Methylene blue as drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2004;127:895-6.
Andresen M, Dougnac A, Díaz O, Hernández G, Castillo L, Bugedo G, et al. Use of methylene blue in patients with refractory septic shock: Impact on hemodynamics and gas exchange. J Crit Care 1998;13:164-8.
Donati A, Conti G, Loggi S, Münch C, Coltrinari R, Pelaia P, et al. Does methylene blue administration to septic shock patients affect vascular permeability and blood volume? Crit Care Med 2002;30:2271-7.
Paciullo CA, McMahon Horner D, Hatton KW, Flynn JD. Methylene blue for the treatment of septic shock. Pharmacotherapy 2010;30:702-15.
Grayling M, Deakin CD. Methylene blue during cardiopulmonary bypass to treat refractory hypotension in septic endocarditis. J Thorac Cardiovasc Surg 2003;125:426-7.
Flynn BC, Sladen RN. The use of methylene blue for vasodilatory shock in a pediatric lung transplant patient. J Cardiothorac Vasc Anesth 2009;23:529-30.
Del Duca D, Sheth SS, Clarke AE, Lachapelle KJ, Ergina PL. Use of methylene blue for catecholamine-refractory vasoplegia from protamine and aprotinin. Ann Thorac Surg 2009;87:640-2.
Leyh RG, Kofidis T, Strüber M, Fischer S, Knobloch K, Wachsmann B, et al. Methylene blue: The drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass? J Thorac Cardiovasc Surg 2003;125:1426-31.
Levin RL, Degrange MA, Bruno GF, Del Mazo CD, Taborda DJ, Griotti JJ, et al. Methylene blue reduces mortality and morbidity in vasoplegic patients after cardiac surgery. Ann Thorac Surg 2004;77:496-9.
Ozal E, Kuralay E, Yildirim V, Kilic S, Bolcal C, Kücükarslan N, et al. Preoperative methylene blue administration in patients at high risk for vasoplegic syndrome during cardiac surgery. Ann Thorac Surg 2005;79:1615-9.
Maslow AD, Stearns G, Butala P, Schwartz CS, Gough J, Singh AK, et al. The hemodynamic effects of methylene blue when administered at the onset of cardiopulmonary bypass. Anesth Analg 2006;103:2-8.
Weiner MM, Lin HM, Danforth D, Rao S, Hosseinian L, Fischer GW, et al. Methylene blue is associated with poor outcomes in vasoplegic shock. J Cardiothorac Vasc Anesth 2013;27:1233-8.
Bhalla T, Sawardekar A, Russell H, Tobias JD. The role of methylene blue in the pediatric patient with vasoplegic syndrome. World J Pediatr Congenit Heart Surg 2011;2:652-5.
Abdelazim R, Salah D, Labib H, El Midany A. Methylene blue compared to norepinephrine in the management of vasoplegic syndrome in pediatric patients after cardiopulmonary bypass: A randomized controlled study Egyptian. J Anaesth 2016;32:269-75.
Wernovsky G, Wypij D, Jonas RA, Mayer JE Jr., Hanley FL, Hickey PR, et al. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants. A comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation 1995;92:2226-35.
Reynolds HR, Hochman JS. Cardiogenic shock: Current concepts and improving outcomes. Circulation 2008;117:686-97.
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:801-10.
Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, et al. EuroSCORE II. Eur J Cardiothorac Surg 2012;41:734-44.
Haase M, Bellomo R, Matalanis G, Calzavacca P, Dragun D, Haase-Fielitz A, et al. Acomparison of the RIFLE and acute kidney injury network classifications for cardiac surgery-associated acute kidney injury: A prospective cohort study. J Thorac Cardiovasc Surg 2009;138:1370-6.
ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: The berlin definition. JAMA 2012;307:2526-33.
Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al. An updated definition of stroke for the 21st century: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:2064-89.
Gando S, Kameue T, Nanzaki S, Hayakawa T, Nakanishi Y. Participation of tissue factor and thrombin in posttraumatic systemic inflammatory syndrome. Crit Care Med 1997;25:1820-6.
Mehaffey JH, Johnston LE, Hawkins RB, Charles EJ, Yarboro L, Kern JA, et al. Methylene blue for vasoplegic syndrome after cardiac operation: Early administration improves survival. Ann Thorac Surg 2017;104:36-41.
Evora PR, José Rodrigues A, Celotto AC. “Methylene blue should be relegated to rescue use and not as first-line therapy” cannot become a paradigm. J Cardiothorac Vasc Anesth 2014;28:e11-2.
Landoni G, Pasin L, Di Prima AL, Dossi R, Taddeo D, Zangrillo A, et al. Methylene blue: Between scylla (meta-analysis) and charybdis (propensity). J Cardiothorac Vasc Anesth 2014;28:e12-3.
Mazzeffi M, Hammer B, Chen E, Caridi-Scheible M, Ramsay J, Paciullo C, et al. Methylene blue for postcardiopulmonary bypass vasoplegic syndrome: A cohort study. Ann Card Anaesth 2017;20:178-81.
Juffermans NP, Vervloet MG, Daemen-Gubbels CR, Binnekade JM, de Jong M, Groeneveld AB, et al. Adose-finding study of methylene blue to inhibit nitric oxide actions in the hemodynamics of human septic shock. Nitric Oxide 2010;22:275-80.
Evora PR, Alves Junior L, Ferreira CA, Menardi AC, Bassetto S, Rodrigues AJ, et al. Twenty years of vasoplegic syndrome treatment in heart surgery. Methylene blue revised. Rev Bras Cir Cardiovasc 2015;30:84-92.