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J Cardiothorac Vasc Anesth. 2016 Apr;30(2):423-7. doi: 10.1053/j.jvca.2015.09.011. Epub 2015 Sep 25.

The Blue Coma: The Role of Methylene Blue in Unexplained Coma After Cardiac Surgery.

Author information

1
Department of Anesthesia and Intensive Care.
2
Department of Neurology, IRCCS San Raffaele Scientific Institute.
3
Department of Anesthesia and Intensive Care; Vita-Salute San Raffaele University, Milano, Italy.
4
Department of Anesthesia and Intensive Care; Vita-Salute San Raffaele University, Milano, Italy. Electronic address: landoni.giovanni@hsr.it.

Abstract

OBJECTIVES:

Methylene blue commonly is used as a dye or an antidote, but also can be used off label as a vasopressor. Serotonin toxicity is a potentially lethal and often misdiagnosed condition that can result from drug interaction. Mild serotonin toxicity previously was reported in settings in which methylene blue was used as a dye. The authors report 3 cases of life-threatening serotonin toxicity in patients undergoing chronic selective serotonin reuptake inhibitor (SSRI) therapy who also underwent cardiac surgery and received methylene blue to treat vasoplegic syndrome.

DESIGN:

An observational study.

SETTING:

A cardiothoracic intensive care unit (ICU) in a teaching hospital.

PARTICIPANTS:

Three patients who received methylene blue after cardiac surgery, later discovered to be undergoing chronic SSRI therapy.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

All 3 patients received high doses of fentanyl during general anesthesia. They all developed vasoplegic syndrome and consequently were given methylene blue in the ICU. All 3 patients developed serotonin toxicity, including coma, after this administration and diagnostic tests were negative for acute intracranial pathology. Coma lasted between 1 and 5 days. Two patients were discharged from the ICU shortly after awakening, whereas the third patient experienced a complicated postoperative course for concomitant refractory low-cardiac-output syndrome.

CONCLUSIONS:

Patients undergoing chronic SSRI therapy should not be administered methylene blue to treat vasoplegic syndrome.

KEYWORDS:

anesthesia; coma; intensive care; methylene blue; selective serotonin reuptake inhibitors; serotonin syndrome; thoracic surgery; vasoplegic syndrome

PMID:
26703972
DOI:
10.1053/j.jvca.2015.09.011
[Indexed for MEDLINE]

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