Methylene blue for clinical anaphylaxis treatment: a case report

CONTEXT AND OBJECTIVE: Nitric oxide has a pathophysiological role in modulating systemic changes associated with anaphylaxis. Nitric oxide synthase inhibitors may exacerbate bronchospasm in anaphylaxis and worsen clinical conditions, with limited roles in anaphylactic shock treatment. The aim here was to report an anaphylaxis case (not anaphylactic shock), reversed by methylene blue (MB), a guanylyl cyclase inhibitor. CASE REPORT: A 23-year-old female suddenly presented urticaria and pruritus, initially on her face and arms, then over her whole body. Oral antihistamine was administered initially, but without improvement in symptoms and signs until intravenous methylprednisolone 500 mg. Recurrence occurred after two hours, plus vomiting. Associated upper respiratory distress, pulmonary sibilance, laryngeal stridor and facial angioedema (including erythema and lip edema) marked the evolution. At sites with severe pruritus, petechial lesions were observed. The clinical situation worsened, with dyspnea, tachypnea, peroral cyanosis, laryngeal edema with severe expiratory dyspnea and deepening unconsciousness. Conventional treatment was ineffective. Intubation and ventilatory support were then considered, because of severe hypoventilation. But, before doing that, based on our previous experience, 1.5 mg/kg (120 mg) bolus of 4% MB was infused, followed by one hour of continuous infusion of another 120 mg diluted in dextrose 5% in water. Following the initial intravenous MB dose, the clinical situation reversed completely in less than 20 minutes, thereby avoiding tracheal intubation. CONCLUSION: Although the nitric oxide hypothesis for MB effectiveness discussed here remains unproven, our intention was to share our accumulated cohort experience, which strongly suggests MB is a lifesaving treatment for anaphylactic shock and/or anaphylaxis and other vasoplegic conditions

Cardiopulmonary Bypass Ischemic Hepatitis Reported in Five Patients

Abstract Objective: In cardiac surgery, the lung, renal and neurological events are the most frequent complications. Less common, acute liver failure is a serious complication that adds high morbidity, mortality, and costs. Therefore, this communication aimed to retrospectively evaluate five patients who presented, in 2014, severe acute liver failure in the immediate postoperative period. Methods: Retrospective data analysis of patients' medical records that showed severe liver failure has been computed in the medical records of five patients undergoing cardiac surgery at the Hospital da Faculdade de Medicina de Ribeirão Preto – USP in the immediate postoperative period from February 1, 2014 to December 12, 2014. The study selected five males patients, 60 to 67 years old, cardiopulmonary bypass mean time of 101.4 minutes (varying from 80 to 140 minutes), who presented acute perioperative liver failure. Results: The five patients showed an impressive increase of blood transaminase (serum alanine aminotransferase), suggesting acute hepatitis. The evolution of all patients was catastrophic, with severe hemodynamic effects and death. Many studies suggest that systemic hypotension is an important pathogenic factor for ischemic hepatitis. However, our data and previous studies raise the possibility that other yet unknown factors other than hypotension may be part of the pathophysiology of cardiopulmonary bypass after ischemic hepatitis (anticoagulation inadequate for the quality of heparin and protamine, etc.). Conclusion: Currently, there are no conclusive studies on the prevention of perioperative liver failure. More well-designed studies are needed on the introduction and evolution of liver dysfunction after cardiac surgery