Methylene Blue in Management of Vasoplegic Shock Secondary to Primidone Overdose

Vasoplegic shock refractory to vasopressors is associated with significant morbidity and mortality. Catecholamine driven therapies are first-line in the management of vasoplegic shock. Research regarding the use of non-catecholamine agents in the setting of refractory vasoplegic shock is lacking. Methylene blue has multiple off-labelled indications for use, but recently has been suggested to have a role in treating vasoplegic shock. Vasoplegic shock is mediated by dysregulation of nitric oxide, which is generated via nitric oxide synthase. Methylene blue inhibits endothelial nitric oxide synthase and restores vascular tone through nitric oxide upregulation. Our case describes hemodynamic improvement following administration of a one-time dose of methylene blue in the management of refractory vasoplegic shock due to primidone overdose. Within 36 hours, he was titrated off all vasopressors with clinical improvement. This case report demonstrates the possible role of single-dose methylene blue in refractory vasoplegic shock.