Heavy Lies the Helmet Episode 117 - Dye or Die: Methylene Blue w/Will Heuser
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Feb 28, 2024 Will Heuser, a Flight Paramedic, Pharmacist, Toxicologist, and Professor, discusses methylene blue's benefits beyond treating methaemoglobinaemia. Topics include its role in septic shock, pathophysiology of distributive shock, pharmacodynamics, pharmacokinetics, and impact on endothelial relaxation. The podcast explores methylene blue in shock management, vasopressor requirements, overdose treatment with high dose insulin, and admiration for mentor Sean Nord.
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Inducible NO Is The Target
- Methylene blue targets inducible nitric oxide synthase rather than constitutive nitric oxide pathways.
- That selectivity explains why it can reverse vasoplegia without destroying baseline nitric oxide physiology.
Vasopressor-Sparing, Mortality Unclear
- Trials show methylene blue reduces vasopressor requirements but not yet clear mortality benefit.
- Smaller trial sizes and endpoints focused on norepinephrine-sparing may explain lack of mortality signal so far.
Use Methylene Blue As Early Adjunct
- Give methylene blue after fluid resuscitation and after norepinephrine plus vasopressin if MAP remains low.
- Use 1–2 mg/kg bolus over an hour, repeat doses or follow with 0.25 mg/kg/hr infusion as needed within 24 hours.