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Methylene blue? Therapeutic Alternative in the Management of Septic Shock Refractory to Norepinephrine

  • Cristian Aragón-Benedí1
  • Ana Pascual-Bellosta2
  • Sonia Ortega-Lucea2
  • Luisa Lacosta-Torrijos2
  • Teresa Jiménez-Bernadó3
  • Javier Martínez-Ubieto2
  • Research group in anesthesia resuscitation and perioperative medicine of Institute for Health Research Aragón

1Department of Anesthesia, Resuscitation and Pain Therapy, Mostoles General University Hospital, Mostoles 28935, Madrid, Spain

2Department of Anesthesia, Resuscitation and Pain Therapy, Miguel Servet University Hospital, Zaragoza 50009, Spain

3Department of Health Sciences, University of Zaragoza, Zaragoza 50009, Spain

DOI: 10.22514/sv.2020.16.0063 Vol.16,Issue 2,October 2020 pp.199-202

Published: 28 October 2020

*Corresponding Author(s): Cristian Aragón-Benedí E-mail:


Introduction: Methylene blue is receiving special interest in perioperative and intensive care of patients with distributive shock due to its ability to block the action of nitric oxide and to antagonize deep vasodilation. Objective: The objective is to illustrate the use of the methylene blue, summarizing the perioperative management of a case with secondary vasoplegic syndrome due to a norepinephrine refractory septic shock and the response to methylene blue, reviewing the latest evidence of this therapeutic alternative. In practice:We describe the case of a 60-year-old man, paraplegic, with septic shock due to a long evolution decubitus pressure ulcer. After two hours of surgery, the patient remained with hemodynamic deterioration despite high doses of vasopressin (3 IU/hour) and norepinephrine (2 µg/kg /min), therefore methylene blue was administered with two intravenous bolus doses of 50 mg without adverse effects. After half an hour hemodynamic improvement was evidenced, allowing to decrease norepinephrine infusion and normalizing blood pressure. Finally, debridement of necrotic tissue, amputation and disarticulation of left coxofemoral joint was performed with subsequent transfer to the ICU and discharge to the spinal cord injury ward twenty eight days later. Conclusions: As it has been demonstrated in our patient, methylene blue is a therapeutic alternative to manage patients with persistent hypotension despite the use of various vasopressors during the management of vasoplegic syndrome secondary to septic shock.


Septic shock, Methylene blue, Surgical intensive care, Vasoplegic syndrome

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Cristian Aragón-Benedí,Ana Pascual-Bellosta,Sonia Ortega-Lucea,Luisa Lacosta-Torrijos,Teresa Jiménez-Bernadó,Javier Martínez-Ubieto,Research group in anesthesia resuscitation and perioperative medicine of Institute for Health Research Aragón. Methylene blue? Therapeutic Alternative in the Management of Septic Shock Refractory to Norepinephrine. Signa Vitae. 2020. 16(2);199-202.


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