Extended Continuous Infusion of Methylene Blue for Refractory Septic Shock

Objective: Highlight the utility of methylene blue (MTB) infusion for extended period for refractory vasoplegia. Introduction: Hypotension refractory to vasopressor therapy in sepsis is associated with high mortality and limited therapeutic options. Dysregulated nitric oxide (NO) pathway seems to be a major driver, and, therefore, MTB, which inhibits inducible NO synthase activity and decreases cyclic guanosine monophosphate (GMP) accumulation by directly competing with NO by binding to soluble guanylyl cyclase, has been explored. Case description: We describe a successful reversal of refractory septic shock with prolonged MTB infusion in a patient supported on multiple vasopressors at the highest clinical doses as well as venovenous extracorporeal membrane oxygenation (VV-ECMO). Conclusion and clinical significance: Current report suggests a potential role of MTB infusion in refractory vasoplegia even in advanced vasoplegic shock.