Journal review

14 Sep 2023
Panika P.
1st year resident
EM CMU
01 Introduction
 Methylene Blue

● Methylene blue (MB) is a specific inhibitor of the inducible

nitric oxide synthase (iNOS) and its downstream enzyme
soluble guanylate cyclase
● Nitric oxide (NO) is a potent smooth muscle dilator. Excessive
NO production can lead to vasoplegic syndrome.
● Methylene blue is used to treat hypotension caused by
vasoplegic syndrome.
 Septic shock

● Catecholamine vasopressors is associated with an increased

risk of multiple organ failure and death in septic shock.
● The time of norepinephrine requirement is a justified
intermediate patient-centered outcome.
Can early adjunctive methylene blue
reduce time to vasopressor
discontinuation in septic shock ?
02 Methods
 Method

● Investigator-initiated , parallel , double blinded

randomized controlled trial in a medical - surgical
intensive care unit (ICU) at an academic reference center
of Mexico.
 Method

● Approved by the institutional review board “Comité de Ética

en Investigación Hospital Civil Fray Antonio Alcalde”
(HCG/CEI- 0252/17)
● This trial was registered at clinicaltrials.gov (NCT04446871)
after inclusion of 17 patients.
● Informed consent was obtained from all patients or
decision makers.
 Inclusion criteria

● Aged >= 18 years with septic shock defined by sepsis-3

criteria
○ Highly suspected or confirmed infection, requiring
norepinephrine to maintain a MAP≥65 mmHg
○ Serum lactate>2 mmol/L after adequate fluid
resuscitation
 Exclusion criteria
● >24 h since initiation of norepinephrine
● Pregnancy
● High probability of death within 48 h
● Concurrent hemorrhagic, obstructive or hypovolemic shock, pending
damage control surgery
● major burn injury
● Personal or familiar history of glucose-6-phosphate dehydrogenase
deficiency
● Allergy to methylene blue, phenothiazines, or food dyes
● Recent intake (4-weeks) of selective serotonin reuptake inhibitors
● Refusal of the patient or decision maker to participate.
 Exclusion criteria

● Due to COVID-19 pandemic, data safety monitoring board

did not allow to recruit patient with COVID-19 infection due to
unknown pathophysiologic and uncertainties about
response to MB
 Randomization and intervention

● Patients were randomly assigned to receive MB using a predetermined

randomization sequence prepared in sealed opaque envelopes.
● The sequence was generated by computer with a 1:1 allocation ratio,
using permuted blocks with a size of 4.
● Critical care physicians were responsible for assignment of
intervention.
● Patients, clinicians, investigators and outcome assessors were blinded
to the treatment received.
 Randomization and intervention
● Septic shock is guided by dynamic tests for prediction of volume
responsiveness before any IV fluid load
○ Aortic velocity-time integral (VTI) change after passive leg
raising ( cut-off 10% )
○ Arterial pulse pressure variation ( cut-off 13% )
○ Tidal volume challenge ( cut-off 3.5%)
○ Respiratory variation of carotid peak flow velocity (cut-off 14%)
● Adequate fluid resuscitation = at least 500 ml bolus of balanced
crystalloid then negative result at least 2 different methods.
 Intervention

MB group Control group

100 mg of MB in NSS 500 ml of NSS IV
500 ml IV over 6 hr over 6 hr once daily
once daily for a total for a total 3 days
of 3 doses

In order to avoid visual identification of the infusion, all infusion bags and
polyvinylchloride lines were prepared at central pharmacy with opaque
envelopes.
 Intervention

● In both groups, Adjunctive vasopressin was initiated at a dose of 0.03

IU/min if norepinephrine dose reached 0.25 mcg/kg/min.
● Evaluation of volume responsiveness was repeated at least 3 times a
day as long as vasopressors were needed.
● Hydrocortisone 200 mg/day by continuous infusion.
○ Withhold within 6 hr after discontinuation of all vasopressor
without taper corticosteroid.
 Intervention

● Vasopressor tapering protocol titrated NE down at 15-20 min intervals

to maintain MAP 65 - 75 mmHg
● After complete discontinuation NE, vasopressin was progressively
withdrawn by 0.005 iu/min each hour.
 Septic shock

Start NE
Titrated q 15 - 20 min to
maintain MAP 65 - 75 mmHG
Evaluation at least 3 times a day NE reached >= 0.25 mcg/kg/min

Start Vasopressin initiated at

a dose 0.03 iu/min

Hydrocortisone 200 mg/day

Taper off NE first
Then taper off vasopressin by withdrawn 0.005 iu/min each hour
 Recorded information

● Demographic, ventilatory and laboratory data, including diagnosis of

acute respiratory distress syndrome (ARDS) defined according to Berlin
criteria
● Norepinephrine dose was recorded at randomization, immediately
after each dose of intervention drug, at 24- and 48-h post-treatment,
for a total of 4 days.
 Recorded information

● POCUS was perform at enrollment and as-needed by critical care

physicians, who are all certified trainers of the WINFOCUS (World
Interactive Network Focused on Critical Ultrasound,
https://www.winfocus.org/) international training unit.
● Ejection fraction was calculated by Teichholz’s method.
● Methemoglobin capillary saturation was continuously monitor by pulse
co-oximetry along intervention.
 Outcome measurement
● All patients were followed up until 28 days of enrollment

● Primary outcome ● Secondary outcome

○ Time to vasopressor ○ Vasopressor-free days at 28 days
discontinuation ( all ○ All-cause mortality at 28 days
vasopressors for at ○ Serum lactate levels
least 48 hr) ○ Days on MV
○ LOS in ICU and hospital
○ Change in serum Cr, TB,AST,ALT ,
PaO2/FiO2 ratio and ejection
fraction
 Calculated sample size

● According to previous study , Calculated sample size was 88

participants for the trial to provide a statistical power of 80% and error
of 0.05.
● We aimed to recruit 92 patients in total ( 46 per group )
 Statistical analysis

● Numeric data expressed as percentage , using Fisher’s exact test.

● Normally distributed data are expressed as mean with standard
deviation.
● Skewed data are expressed as median with IQR
● Mann-whitney U test and student T test were used.
● A kaplan-meire curve was plotted for vasopressor discontinuation and
analyzed with death as a competing risk event.
 Statistical analysis

● All p-value were two sided.

● Outcomes were analyzed on an intention to treat basis.
03 Results
 Results
● 308 participants were assessed.
● 92 patients underwent randomization
○ 46 in MB group
■ 1 in MB group withdrew consent after receiving 1st
dose
○ 46 in control group
■ 1 in control group died before receiving 3rd dose
● 91 patients were included in the analysis.
 Results
● All patients received antibiotic within 3 hr of septic shock diagnosis
and also hydrocortisone was given to all.
● The daily weight dose of MB was 1.2 mg/kg ( IQR 1.1 - 1.4 )
● No other vasopressor / inotrope ( except NE ) were used.
● Proportional hazards
analysis, HR for shock
reversal ( vasopressor
discontinuation ) of 2.7 in
MB group , P = 0.0007
 Results
● Most common adverse effect was green-blue discoloration of urine
in 42 of 45 ( 93 % ) in MB group.
● Maximum methemoglobin saturation was significantly higher in MB
group , 2.9 % in MB group and 0.5 % in control group , P < 0.001
● The change in ejection fraction , PF ratio , creatinine , bilirubin ,
hepatic enzymes were not different between groups.
04 Discussion
 Discussion

● About previous RCTs

○ Compare N-methyl-L-arginine hydrochloride which is non selective
inhibit both inducible and constitutive form of NOS >> the study
was early terminated due to increase mortality.
○ MB in this study >> selectively inhibit only inducible form of NOS
○ Constitutive isoform is important to maintain homeostasis and
microcirculatoryblood flow.
Discussion : From previous RCTs

MB 2 mg/kg bolus MB 3 mg / kg over 6 hr

Followed by
continuous infusion
( total 5.75 mg/kg )

no statistically significant compared to placebo

Discussion : From previous RCTs

MB 3 mg/kg IV bolus MB 4 mg / kg IV
Over 10 min over 4 hr

Significantly decreased of PF ratio

Ref: Revista Brasileira de Anestesiologia, 2008
 Discussion : From previous RCTs

● Previous study about dose related - adverse effect of MB

○ MB 7 mg / kg : compromise splanchnic perfusion.
○ Continuous prolonged infusion time lead to high cumulative
dose and result in Methemoglobinemia.

Toxicity of MB is dose - related and adverse effect are rarely present

under 2 mg / kg.
 Discussion for this study

● Dose of MB in this study = 1 mg / kg fixed dose , Total

cumulative dose of 3.6 mg/kg over 54 h
○ Lower than previous study
○ Results showed that 1 mg/kg was enough to improve MAP ,
LV function and tissue oxygenation.
○ No effects in pulmonary , kidney , cardiac or liver function.
○ Methemoglobin levels was under toxicity threshold.
 Discussion for this study

● The adjunctive MB administered within 24 hr of septic shock

diagnosis can reduce time to vasopressor discontinuation.
● No severe adverse effect were detected.
● Lower cost than other catecholamine-sparing agents
● MB might shift from rescue therapy to early adjunctive therapy
for septic shock.
 Limitations

Single - centered Intensive care Time from

study resuscitation enrollment to
Shorter LOS in mexico before admission intervention

Change in SSC Nitrates level can Urine discoloration ,

during study not be measured level of metHb
could lead to bias
 Limitations

● COVID-19 not included in this study.

● This study was underpowered to draw any conclusion on this
outcome. The difference in mortality trends between groups
should be cautiously interprete.
 Conclusions

● Early adjunctive MB reduced vasopressor duration ,

cumulative fluid balance , ICU and hospital length of stay
among septic shock patients compare to placebo.
● Larger multicentered RCTs should be done before confirm the
potential benefit of MB.
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THANK YOU
SCAN
HERE