Methylene Blue

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I've recently started seeing methylene blue being used in ICU. My understanding is that this is an off-label use for vasoplegia post-cardiac surgery. Just wondering if anyone has personal experience with this. Any other indications? What about vasodilatory shock of other aetiologies?
 
Works as nitric oxide scavenger. It does work but transiently and it does fix the original problem. Also freaks everyone out when pulse ox doesnt read right. I only would go to it when patients is dying and all my other pressors are maxed, steroids are in and HCT>30.
 
Methylene blue has a life threatening side effect everyone who uses it should know about. Any medical students or residents care to jump in?
 
technically every use of this drug is off label, i think. im pretty sure its not fda-approved for any indication

yes i use it for refractory vasoplegia, but typically before the patient is flooded with volume and maxed out three pressors. if i have a high index of suspicion (post-bypass) and am finding myself rapidly escalating therapy then ill add it fairly early. sometimes redosing is required.

i consider that its action is inhibition of NO synthesis rather than as a scavenger.
 
risnwb said:
Blue Urine.
Click to expand...

I have a picture of beautiful blue-green urine from this patient.

What serious side-effect are we talking about? Methhaemoglobin? Haemolytic anaemia in G6PD? Hypertension? I am actually just guessing here.
 
Nope, nope and... possibly on Na'vi. :hungry:

I have two good friend anesthesiologists who have gone through this reaction.
One picked it up early, the other didn't.

Great clinical cases and def. board material.

The FDA sent out a warning a couple years back.
 
Serotonin syndrome. It's an MAOI. Not sure of the dose required...
 
sevoflurane said:
Nope, nope and... possibly on Na'vi. :hungry:

I have two good friend anesthesiologists who have gone through this reaction.
One picked it up early, the other didn't.

Great clinical cases and def. board material.

The FDA sent out a warning a couple years back.
Click to expand...

So other than the paradoxical methemoglobinemia and I'm sure it's not great on the kidneys I had no idea. Looked it up in MicroMedex and it lists MH and Serotonin Syndrome as potential serious complications. I'd definitely never read, or remembered reading that atleast.

Quick google-fu and looks like FDA alert was for Serotonin Syndrome.
 
If you patient is taking any of the following drugs, they could be at risk of serotonin syndrome if you give methylene blue.


http://www.fda.gov/Drugs/DrugSafety/ucm263190.htm

Tables -Psychiatric medications with serotonergic activity

Selective Serotonin Reuptake Inhibitors (SSRIs)
Generic nameFound in Brand name(s)
paroxetinePaxil, Paxil CR, Pexeva
fluvoxamineLuvox, Luvox CR
fluoxetineProzac, Sarafem, Symbyax
sertralineZoloft
citalopramCelexa
escitalopramLexapro

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Generic nameFound in Brand name(s)
venlafaxineEffexor, Effexor XR
desvenlafaxinePristiq
duloxetineCymbalta

Tricyclic Antidepressants (TCAs)
Generic nameFound in Brand name(s)
amitriptylineAmitid, Amitril, Elavil, Endep, Etrafon, Limbitrol, Triavil
desipramineNorpramin, Pertofrane
clomipramineAnafranil
imipramineTofranil, Tofranil PM, Janimine, Pramine, Presamine
nortriptylinePamelor, Aventyl hydrochloride
protriptylineVivactil
doxepinSinequan, Zonalon, Silenor
trimipramineSurmontil

Monoamine Oxidase Inhibitors (MAOIs)
Generic nameFound in Brand name(s)
IsocarboxazidMarplan
PhenelzineNardil
SelegilineEmsam, Eldepryl, Zelapar
TranylcypromineParnate

Other Psychiatric Medications
Generic nameFound in Brand name(s)
amoxapineAsendin
maprotilineLudiomil
nefazodoneSerzone
trazodoneDesyrel, Oleptro, Trialodine
bupropionWellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban, Aplenzin
buspironeBuspar
vilazodoneViibryd
mirtazapineRemeron, Remeron Soltab
 
Yup. Seratonin Syndrome which may be confused with MH. Both had several antipsychotic/seratonin reuptake meds on board.

Good job Home-E's.

Both cases were after methylene blue administration for parathyroid surgery.
 
We use methylene blue a decent amount actually. And I'd bet 25%, as a conservative estimate, of the patients at our shop are on atleast one of the SSRI/SNRI/TCA's.

Good to know.
 
kazuma said:
If you patient is taking any of the following drugs, they could be at risk of serotonin syndrome if you give methylene blue.
http://www.fda.gov/Drugs/DrugSafety/ucm263190.htm

Tables -Psychiatric medications with serotonergic activity

Selective Serotonin Reuptake Inhibitors (SSRIs)
Generic nameFound in Brand name(s)
paroxetinePaxil, Paxil CR, Pexeva
fluvoxamineLuvox, Luvox CR
fluoxetineProzac, Sarafem, Symbyax
sertralineZoloft
citalopramCelexa
escitalopramLexapro
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Generic nameFound in Brand name(s)
venlafaxineEffexor, Effexor XR
desvenlafaxinePristiq
duloxetineCymbalta

Tricyclic Antidepressants (TCAs)
Generic nameFound in Brand name(s)
amitriptylineAmitid, Amitril, Elavil, Endep, Etrafon, Limbitrol, Triavil
desipramineNorpramin, Pertofrane
clomipramineAnafranil
imipramineTofranil, Tofranil PM, Janimine, Pramine, Presamine
nortriptylinePamelor, Aventyl hydrochloride
protriptylineVivactil
doxepinSinequan, Zonalon, Silenor
trimipramineSurmontil

Monoamine Oxidase Inhibitors (MAOIs)
Generic nameFound in Brand name(s)
IsocarboxazidMarplan
PhenelzineNardil
SelegilineEmsam, Eldepryl, Zelapar
TranylcypromineParnate

Other Psychiatric Medications
Generic nameFound in Brand name(s)
amoxapineAsendin
maprotilineLudiomil
nefazodoneSerzone
trazodoneDesyrel, Oleptro, Trialodine
bupropionWellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban, Aplenzin
buspironeBuspar
vilazodoneViibryd
mirtazapineRemeron, Remeron Soltab
Click to expand...


That is a big list and exactly why I wanted to mention this reaction.
 
Per4mer8 said:
We use methylene blue a decent amount actually. And I'd bet 25%, as a conservative estimate, of the patients at our shop are on atleast one of the SSRI/SNRI/TCA's.
Click to expand...

I can count with 1 hand the number of times I have used it. I have only seen one patient "benefit" from it. And thats with routine super long bypass times.

Are you using it prophylactically, or do you honestly think that many of your patients are vasoplegic?
 
An attending I work with likes to give it and not tell perfusion. The reactions are humorous.
 
Didn't Wake forest or Duke (I don't remember exactly who...) use it routinely for all patients on ACE inhibitors and ARBs 3-4 years ago?
I don't use it often, probably a hand full of times over the last couple of years. Sometimes with good response and sometimes not.

http://www.ncbi.nlm.nih.gov/pubmed/16790616

The dose is 1.5mg/kg over 15-20 minutes.

Overall, it's a pretty benign drug targeting nitric oxide synthase.
 
sevoflurane said:
Didn't Wake forest or Duke (I don't remember exactly who...) use it routinely for all patients on ACE inhibitors and ARBs 3-4 years ago?
I don't use it often, probably a hand full of times over the last couple of years. Sometimes with good response and sometimes not.

http://www.ncbi.nlm.nih.gov/pubmed/16790616

The dose is 1.5mg/kg over 15-20 minutes.

Overall, it's a pretty benign drug targeting nitric oxide synthase.
Click to expand...


Just need to watch out for Seratonin Syndrome, especially in patients with ESRD.
 
G6PD is probably a bigger concern if you practiced in asia, the middle east, africa etc. Not so common in the US. I think I've seen one or two in the last 5 years.
Give 'em some Fava beans and see what happens if you're concerned. :dead: :pompous:
 
will worsen pulmonary arterial hypertension as well, potentially. i dont throw it around haphazardly. ill do 1mg/kg over 20-30 minutes and then redose it in 90-120 minutes if needed
 
sevoflurane said:
G6PD is probably a bigger concern if you practiced in asia, the middle east, africa etc. Not so common in the US. I think I've seen one or two in the last 5 years.
Give 'em some Fava beans and see what happens if you're concerned. :dead: :pompous:
Click to expand...
G6PD and sickle cell are the two genetic conditions everyone in the US military is tested for upon entry. I've run into a dozen or 15 patients at military hospitals with it, don't think I've ever seen it in the civilian world (no one's looking). I don't know much about the test the military uses, and since not all G6PD is created equal, I bet a lot of asymtomatic/mild variants get flagged in the military. (The military cares about G6PD because we send people to hot mosquito-infested places and routinely put people on antimalarial drugs.)

CSB - I was a blissfully unaware newish CA1 when one day I was in a urology case and gave it to a G6PD deficient patient at the surgeon's request. The worst thing that happened was the scolding I got from my attending, no effect on the patient.
 
Back in recent residency we had a couple people develop anaphylaxis from it. I believe one was fatal.
 
kazuma said:
If you patient is taking any of the following drugs, they could be at risk of serotonin syndrome if you give methylene blue.


http://www.fda.gov/Drugs/DrugSafety/ucm263190.htm

Tables -Psychiatric medications with serotonergic activity

Selective Serotonin Reuptake Inhibitors (SSRIs)
Generic nameFound in Brand name(s)
paroxetinePaxil, Paxil CR, Pexeva
fluvoxamineLuvox, Luvox CR
fluoxetineProzac, Sarafem, Symbyax
sertralineZoloft
citalopramCelexa
escitalopramLexapro

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Generic nameFound in Brand name(s)
venlafaxineEffexor, Effexor XR
desvenlafaxinePristiq
duloxetineCymbalta

Tricyclic Antidepressants (TCAs)
Generic nameFound in Brand name(s)
amitriptylineAmitid, Amitril, Elavil, Endep, Etrafon, Limbitrol, Triavil
desipramineNorpramin, Pertofrane
clomipramineAnafranil
imipramineTofranil, Tofranil PM, Janimine, Pramine, Presamine
nortriptylinePamelor, Aventyl hydrochloride
protriptylineVivactil
doxepinSinequan, Zonalon, Silenor
trimipramineSurmontil

Monoamine Oxidase Inhibitors (MAOIs)
Generic nameFound in Brand name(s)
IsocarboxazidMarplan
PhenelzineNardil
SelegilineEmsam, Eldepryl, Zelapar
TranylcypromineParnate

Other Psychiatric Medications
Generic nameFound in Brand name(s)
amoxapineAsendin
maprotilineLudiomil
nefazodoneSerzone
trazodoneDesyrel, Oleptro, Trialodine
bupropionWellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban, Aplenzin
buspironeBuspar
vilazodoneViibryd
mirtazapineRemeron, Remeron Soltab
Click to expand...

You may also want to take into consideration if they're septic, if they're on the antibiotic Zyvoz (Linezolid) - it also acts as an MAO-I and has been implicated in serotonin syndrome.
 
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