Methylene Blue for the Treatment of Refractory Hypotension in Polysubstance Overdose.

Methylene blue is a medication that has been traditionally used to treat conditions such as methemoglobinemia and vasoplegia, particularly in patients who have undergone coronary artery bypass procedures. However, recent investigations have explored its potential as a treatment for refractory hypotension, a condition characterized by low blood pressure that is unresponsive to conventional therapies. Various factors, including an overdose of certain medications, such as calcium channel blockers, can cause refractory hypotension. In the case presented, a 67-year-old female patient was admitted to the emergency department (ED) after intentionally ingesting a combination of substances, including metoprolol, amlodipine, and other medications. The patient's condition was marked by severe refractory hypotension, which did not respond to initial treatments, including fluids, calcium chloride, and multiple pressure support medications, such as norepinephrine and vasopressin. To manage the patient's hypotension, insulin and dextrose were administered in addition to methylene blue. The use of methylene blue in this case was based on its mechanism of action, which involves inhibiting guanylate cyclase, an enzyme that produces cyclic guanosine monophosphate (cGMP). By reducing cGMP levels, methylene blue decreases vascular smooth muscle relaxation, leading to vasoconstriction and increased blood pressure. This mechanism makes methylene blue a potential treatment option for refractory vasoplegia and hypotension that is unresponsive to other measures. In this case, the patient's condition improved with methylene blue infusion, highlighting its potential as a therapeutic agent for managing refractory hypotension in patients with polysubstance overdose or other causes of refractory hypotension.

Link: https://pubmed.ncbi.nlm.nih.gov/40026991/