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J Thorac Cardiovasc Surg 2004;127:608
© 2004 The American Association for Thoracic Surgery

Letter to the editor

Angiotensin-converting enzyme inhibitors predispose to hypotension refractory to norepinephrine but responsive to methylene blue

Donatella Sparicio, MD, Giovanni Landoni, MD, Alberto Zangrillo, MD

Vita-Salute University of Milano, IRCCS San Raffaele Hospital, Milano, Italy

To the Editor:

We read with interest the brief communication of Grayling and Deakin1 describing the methylene blue administration in a patient with refractory hypotension during cardiac surgery. We're currently using this drug for patients with high cardiac output and hypotension unresponsive to norepinephrine at doses similar to those suggested by Grayling and Deakin (up to 3 mg/kg in 2 different administration instead of 2 mg/kg in a single dose). We would like to suggest a possible predisposing factor of vasoplegia that responds to methylene blue: in our experience2 and in the literature3-5 it is evident that most episodes of refractory hypotension are related to preoperative intake of angiotensin-converting enzyme inhibitors (ACEI); even the patient described in this report was assuming ACEI (ramipril). After experiencing a dramatic refractory hypotension in a patient on a program of ACEI,2 we started using methylene blue in case of refractory hypotension and withdrawing ACEI the day before surgery. We observed an immediate and sustained response even at doses less than 1 mg/kg.

We would like to reinforce this kind of therapeutic approach and suggest a common predisposing factor that has been so far underestimated: preoperative intake of ACEI.


   References
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 References
 

  1. Grayling M, Deakin CD. Methylene blue during cardiopulmonary bypass to treat refractory hypotension in septic endocarditis. J Thorac Cardiovasc Surg. 2003;125:426–427[Free Full Text]
  2. Pappalardo F, Landoni G, Franco A, Monaco C, Marino G, Torri G. Prolonged refractory hypotension in cardiac surgery after institution of cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2002;16:477–479[Medline]
  3. Yiu P, Robin J, Pattison CW. Reversal of refractory hypotension with single dose methylene blue after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 1999;118:194–195
  4. Pagni S, Austin EH. Use of intravenous methylene blue for the treatment of refractory hypotension after cardiopulmonary bypass. J Thorac Cardiovasc Surg. 2000;119:1297–1298[Free Full Text]
  5. Berkowitz DE, Richardson C, Elliott D, Leslie JB, Schwinn DA. Hypotension resistant to therapy with alpha receptor agonists complicating cardiopulmonary bypass: lithium as a potential cause. Anesth Analg. 1996;82:1082–1085[Free Full Text]

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Reply to the Editor
Joseph A. Dearani, Francisco J. Puga, and Gordon K. Danielson
J. Thorac. Cardiovasc. Surg. 2004 127: 609. [Extract] [Full Text] [PDF]



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