Cyanokit and Methylene Blue for Hypotension

Cyanokit (Hydroxocobalamin)

Dose

• 5g over 15min (full vial) mixed in 200cc NS

Mechanism

• Nitric oxide scavenger

General Administration Guide

1. Increase pressers
2. Give dose
3. Watch for large increase in BP and then slowly back off pressors
4. Generally you have one shot to give a single dose…DO Not Waste It!!!

Side Effects

Increased Blood Pressure

• Allergic Reaction
• Acute renal failure with ATN
• Calcium oxylate urine cyrstals
• Chromaturia (bright red urine)
• Interference with Hgb, Creatine, Glucose levels on lab draws
• Pulse ox changes
• Red colored skin

Methylene Blue

• Along with being quite helpful in hypotension methylene blue is also used to treat methemoglobinemia. This condition is the result of Fe2+ of hemoglobin getting oxidized to Fe3+. This significantly reduces the oxygen carrying capacity of hemoglobin.
• Finally it also has been shown to help in malaria treatment by stopping the immunologically active byproduct production from the Plasmodium species.

Dose

• 1mg/kg over 5-30min for methemoglobinemia

• 2mg/kg over 20min of refractory vasoplegia

• 36-72mg/kg over 3 days for Plasmodium treatment

Mechanism

• Guanylate cyclase inhibitor
• Endothelial nitric oxide synthase enzyme inhibitor
• Inducible nitric oxide synthase inhibitor

Side Effects

Serotonin Syndrome

Increased Blood Pressure

• Decreased pulse ox to approx 85%
• Dark blue/green urine
• Pale skin

Physiology Overview

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Comparison Between Methylene Blue and Hydroxocobalamin

A small sample size study showed no difference between the two treatment options when faced with vasoplegia status post cardiac bypass.

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