Original ArticleThe Blue Coma: The Role of Methylene Blue in Unexplained Coma After Cardiac Surgery
Section snippets
Materials and Methods
Three women undergoing chronic SSRI therapy with paroxetine, citalopram, and sertraline, respectively, underwent cardiac surgery with cardiopulmonary bypass. Anesthesia was induced with propofol, rocuronium, and fentanyl. Anesthesia was maintained with a combination of propofol, rocuronium, sevoflurane, and high doses of fentanyl. Details on the patients are reported in Table 1.
Serotonin toxicity was diagnosed retrospectively in all 3 patients using the Hunter criteria (reported in Table 2).13
Results
All 3 patients (described in Table 3) developed vasoplegic syndrome while sedated with propofol in the intensive care unit (ICU) after surgery and received a continuous infusion of norepinephrine and/or epinephrine. Methylene blue (100 mg over 20 minutes) was administered to reduce the dose of vasoconstrictors and was repeated after a few hours in all patients.
All 3 patients developed coma, for which they underwent neurologic investigation. Their brain computed tomography scans were negative
Discussion
The importance of this case series is that the authors have described, for the first time, 3 cases of unexplained postoperative coma caused by rarely diagnosed, but possibly common, life-threatening serotonin toxicity. The common features among the patients were the regular use of SSRI medication, the administration of methylene blue, and neurologic signs and symptoms.
Conclusions
The off-label use of methylene blue in vasoplegic cardiac surgery patients undergoing chronic SSRI therapy or in those taking other serotonergic drugs must be avoided. In the setting of a postoperative “blue coma,” SSRI therapy should not be restarted and serotonergic drugs should not be added.1, 27
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2020, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :One magic bullet in this scenario is methylene blue.13-15 This agent decreases endothelial production of nitric oxide to enhance systemic vascular tone and thereafter to restore organ perfusion.16-19 Methylene blue can be dramatically effective and has been discussed extensively in the journal.11-17
E.A.M and D.W. contributed equally to this work.