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Publication Date



oregon; portland; psvmc


Internal Medicine



Refractory vasodilatory shock develops from uncontrolled vasodilation and hyporesponsivenessto vasopressors. •Management of calcium channel blockers (CCB) toxicity can be difficult because it can result in refractory vasodilatory

Case Presentation

•21-year-old male with history of depression and prior suicide attempts presented after intentional ingestion of amlodipine (300 mg) and metformin (150 tablets of 1000 mg). •Presented with slightly altered mentation and hypotension, then quickly deteriorated and required intubation and high vasopressor requirements. •Transferred to PSVMC for consideration of venoarterialextracorporeal membrane oxygenation (VA-ECMO). Since he was hyperdynamic on echocardiogram, our team did not feel he would benefit from VA-ECMO. •His vasopressor requirements surpassed the normal recommended doses •Due to no improvement, methylene blue and hydroxycobalamine(vitamin B12) were initiated for his refractory shock. •He responded favorably to this therapy. Norepinephrine dose was halved and Epinephrine down to 10 mcg/min almost immediately. •It took several days to wean him off the vasopressors and he was able to transfer to the medical floor in stable condition.


•Higher doses of vasopressors are typically required for CCB toxicity and co-ingestions can also alter the pharmacokinetics in unpredictable ways. •Emerging therapies, such as methylene blue and vitamin B12, were tried. These have previously been used in cardiac patients who experienced vasoplegiapostoperatively. •Methylene blue and vitamin B12 are thought to increase systemic vascular resistance by decreasing nitric oxide synthesis thereby preventing smooth muscle relaxation allowing vasoconstriction in response to catecholamines (Figure 1). •Both therapies have been used only in case-series and case-reports; there has yet to be randomized trials to validate their use. •Interesting side effect of methylene blue and vitamin B12 depicted in Figure 2 & 3. This resulted in his urine turingpurple. The CRRT sensor needed to be changed so that the machine did not think his urine was blood. •This case highlights the importance of considering alternative therapies such as methylene blue and vitamin B12 in cases of refractory shock unresponsive to standard therapies.


Internal Medicine

Conference / Event Name

Academic Achievement Day, 2021


Providence St. Vincent Medical Center

Overloadipine–Emerging Therapies to Treat Refractory Shock