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J Thorac Cardiovasc Surg 2006;131:250-251
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Methylene blue revised

Division of Thoracic and Cardiovascular Surgery, Ribeirão Preto Faculty of Medicine, University of São Paulo, São Paulo, Brazil

To the Editor:

Recently, Taylor and Holtby ¹ have presented a case of refractory hypotension in a child with native mitral valve endocarditis with cerebral complications in whom methylene blue (MB) was less effective than previously described. ^2,3

We have been using MB to treat refractory vasoplegias since 1994, and our experience is corroborated by the specialized medical literature. Most of our experience involved adults who had hypotension during cardiopulmonary bypass (CPB) or after the operation, situation in which, like sepsis, nitric oxide plays a primordial role. ^4,5 In this milieu two prospective and randomized studies reached positive conclusions about the efficacy of MB to treat ⁶ or prevent ⁷ the vasoplegic syndrome in patients having cardiac surgery with the aid of CPB.

Recently, we operated on a drug-addicted young man with native aortic valve endocarditis. The patient received a bileaflet valve prosthesis (St Jude Medical, Inc, St Paul, Minn). A high dose of norepinephrine was necessary to maintain a reasonable blood pressure during CPB. After weaning from CPB he was hypotensive and had a high cardiac output, low systemic vascular resistance, and pulmonary edema. The arterial oxygen saturation was below 80%, even though he was being ventilated with 100% oxygen and positive end-expiratory pressure. We started MB in a continuous infusion in a way quite similar to that used by Dr Taylor, followed by a bolus of 3 mg/kg (in 100 mL of 5% glucose in water) twice a day. Even though the mean arterial pressure did not increase, even with norepinephrine, the cardiac output gradually decreased, and the systemic vascular resistance increased. In addition, the rapid resolution of lung edema resulting in higher arterial oxygen saturation was astonishing.

Although Drs Taylor and Holtby seemed disappointed with the effect of the MB on blood pressure, we believe that their case had an impressive evolution despite of its severity. We disagree that "obvious clinical improvement using MB was not evident in this case," since most of the pharmacologic support to the circulation was necessary for a short time. In our opinion, the controversy about the use of MB to treat similar cases arises when one uses MB merely as a kind of "last-minute vasopressor." MB sometimes seems to work for this purpose and sometimes it does not, perhaps due the fact that, unlike many vasopressors, MB does not act through a membrane receptor. We believe the pivotal action of MB is not exclusively the guanylyl cyclase blockage resulting in a reduction in cyclic guanosine monophosphate (cGMP). This blockage also enhances the "crosstalk" between cyclic adenosine monophosphate (cAMP) and cGMP pathways, which facilitates the effect of the cAMP-dependent vasopressors. Many clinical reports in the medical literature, including sepsis treatment, substantiate that the guanilyl cyclase blockage seems to improve the effect of the vasopressors, shortening the length of pharmacologic cardiovascular support. Another quite advantageous effect of MB is its capacity to reduce vascular permeability. ^8,9

	References

Top References

 

1. Taylor K, Holtby H. Methylene blue revisited. management of hypotension in a pediatric patient with bacterial endocarditis. J Thorac Cardiovasc Surg 2005;130:566.[Free Full Text]
   
2. Driscoll W, Thurin S, Carrion V, Steinhorn RH, Morin 3rd FC. Effect of methylene blue on refractory neonatal hypotension. J Pediatr 1996;129:904-908.[Medline]
   
3. 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]
   
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;119:632-634.[Free Full Text]
   
5. Evora PRB, Levin RL. Methylene blue as drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2004;127:895-896.[Free Full Text]
   
6. 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;77:496-499.[Abstract/Free Full Text]
   
7. Ozal E, Kuralay E, Yildirim V, Kilic S, Bolcal C, Kucukarslan N, et al. Preoperative methylene blue administration in patients at high risk for vasoplegic syndrome during cardiac surgery. Ann Thorac Surg 2005;79:1615-1619.[Abstract/Free Full Text]
   
8. Kirov MY, Evgenov OV, Evgenov NV, Egorina EM, Sovershaev MA, Sveinbjornsson B, et al. Infusion of methylene blue in human septic shock. a pilot, randomized, controlled study. Crit Care Med 2001;29:1860-1867.[Medline]
   
9. Donati A, Conti G, Loggi S, Munch C, Coltrinari R, Pelaia P, Pietropaoli P, et al. Does methylene blue administration to septic shock patients affect vascular permeability and blood volume?. Crit Care Med 2002;30:2271-2277.[Medline]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alfredo José Rodrigues Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Evora, P. R. B. Articles by Rodrigues, A. J. Search for Related Content PubMed PubMed Citation Articles by Evora, P. R. B. Articles by Rodrigues, A. J. Related Collections Cardiac - pharmacology Extracorporeal circulation Related Article