EM Quick Hits 51 – Methylene Blue in Septic Shock, TMJ Dislocation, Crohn’s Disease, Analgesia for Renal Colic, Inhaled Steroids for Asthma, Hypocalcemia in Bleeding Trauma Patients

Topics in this EM Quick Hits podcast

Anand Swaminathan on the role of methylene blue in septic shock (0:39)

Nour Khatib on TMJ dislocation reduction techniques (5:51)

Hans Rosenberg on a phenotypic approach to Crohn's disease emergencies (10:31)

Gil Yehudaiff on evidence based analgesics for renal colic  (18:23)

Brit Long on the importance of inhaled steroids for asthma (25:22)

Andrew Petrosoniak on hypocalcemia in bleeding trauma patients (35:23)

Podcast production, editing and sound design by Anton Helman

Written summary & blog post by Shaila Gunn, Brit Long, Andrew Petrosoniak, edited by Anton Helman

Cite this podcast as: Helman, A. Swaminathan, A. Khatib, A. Rosenberg, H. Yehudaiff, G. Long, B. Petrosoniak, A.  EM Quick Hits 51 - Methylene Blue in Septic Shock, TMJ Dislocation, Crohn's Disease, Analgesia for Renal Colic, Inhaled Steroids for Asthma, Hypocalcemia in Bleeding Trauma Patients. Emergency Medicine Cases. September, 2023. https://emergencymedicinecases.com/em-quick-hits-september-2023/. Accessed May 30, 2024.

Methylene Blue - a potential adjunct in refractory septic shock

* The first line vasopressor in septic shock, norepinephrine, is associated with risks at high doses and with prolonged use including dysrhythmias, peripheral ischemia, myocardial dysfunction

* Methylene blue may decrease the amount and duration of vasoactive drugs needed in patient with septic shock

* It decreases nitric oxide levels by inhibiting inducible nitric oxide and enzyme soluble guanylate cyclase, which is believed to restore vasoregulation

* The evidence of methylene blue is limited with small studies showing inconsistent evidence in septic shock

A recent study in Critical Care “Early Adjunctive Methylene Blue in Patients with Septic Shock: A single-center, parallel, double blind randomized controlled trial” by Ibarrea-Estrada et al, asked the question: Does methylene blue expedite the discontinuation of pressors in patients with septic shock?

* P: 92 ICU patients, most mechanically ventilated and on norepinephrine and vasopressin

* I: Methylene blue IV infusion 100 mg in 500 cc of 9% normal saline over 6 hours daily x 3 doses

* C: 500 cc of 0.9 % saline

* O: The time to discontinue vasopressors (defined as the discontinuation of all vasopressors for 48 consecutive hours) was 25 hours shorter in the methylene blue group; there was a 1.5 day shorter ICU stay, 2.7 day shorter hospital stay, and a 714 cc lower cumulative fluid balance in the methylene blue group; there was no difference in mechanical ventilation or mortality between groups

Critical Appraisal

* This was a single center trial with a small cohort

* The small cohort is reflective of a selection bias providing limited internal and external validity

* The end-point is not patient centered and may not be clinically relevant

Bottom line => Recent evidence suggests that methylene blue decreases the time spent on vasopressors but does not improve mortality. At this time, the data is not strong enough to recommend the use of methylene blue routinely in vasopressor refractory septic shock, but it can be considered as an adjunct in certain clinical contexts, and our ICU colleagues may be requesting us to administer it, underlying the importance of being familiar with it for this indication.