(1550) Why So Blue? Methylene Blue as a Treatment in Polypharmacy Overdose

Introduction: Deaths related to drug overdose have increased over the last two decades. Outside of drug-specific antidotes, treatment primarily focuses on supportive measures. Evidence is lacking to support a recommendation for the adjunctive use of methylene blue as a treatment option for refractory vasodilatory shock secondary to cardioactive medications.

Description: A 50-year-old female with a history of depression with psychotic features, prior suicide attempts, traumatic brain injury, alcohol use disorder, and chronic pain presented to the emergency department (ER) after unwitnessed intentional overdose of multiple medications. The medications taken include a total of 4.9mg clonidine, 43.2g gabapentin, 170mg cyclobenzaprine, 40g methocarbamol, 140mg duloxetine, 4g magnesium oxide, 30mg olanzapine, 3.6mg tamsulosin, and 300mg bupropion, as well as an unknown amount of trazodone. On arrival, she was severely hypotensive with a mean arterial pressure (MAP) of 35 mmHg, tachycardic to 140 beats per minute, hypoxic despite 100% non-rebreather mask, and was obtunded. The patient was intubated and resuscitated with three liters of crystalloid without a hemodynamic response. She was then started on vasopressors and maintained severe hypotension despite 1 mcg/kg/min of norepinephrine, 0.3 mcg/kg/min of epinephrine, 8 mcg/kg/min of phenylephrine, and 0.08 units/min of vasopressin. Naloxone 2 mg and 150 mEq of sodium bicarbonate were administered without notable change. A 2 mg/kg bolus of methylene blue followed by a continuous infusion of 0.5 mg/kg/hr was started for refractory vasodilatory shock. The methylene blue infusion continued for a total of 21 hours. After 18 hours of the infusion, epinephrine was discontinued, and other vasopressors were reduced by over half while maintaining a MAP greater than 65 mmHg. All vasopressors were discontinued within 43 hours and the patient was successfully extubated without evidence of end-organ damage.

Discussion: Intentional polysubstance overdose with cardioactive medications may result in profound vasodilation despite standard treatment modalities. Our experience describes the successful use of methylene blue as an adjunctive option to achieve hemodynamic stability given its alternative mechanism of action.