title: Methylene blue improves the hepatopulmonary syndrome.
abstract: BACKGROUND
  The hypoxemia of the hepatopulmonary syndrome, seen in patients with severe chronic liver dysfunction, results from widespread pulmonary vasodilation. No established drug therapy is available for this condition.
  
  
  OBJECTIVE
  To study the effect of methylene blue, a potent inhibitor of guanylate cyclase, in patients with severe hepatopulmonary syndrome.
  
  
  METHODS
  Open, uncontrolled trial.
  
  
  METHODS
  Medical intensive care unit at the university hospital in Vienna, Austria.
  
  
  METHODS
  7 patients with advanced cirrhosis and severe hepatopulmonary syndrome with PaO(2) of 60 mm Hg or less.
  
  
  METHODS
  Insertion of a pulmonary artery catheter and an arterial indwelling catheter; intravenous administration of methylene blue, 3 mg/kg of body weight, over a 15-minute period.
  
  
  METHODS
  Serial measurements of gas exchange and hemodynamic variables.
  
  
  RESULTS
  After methylene blue administration, PaO(2) increased in all patients (from a baseline mean +/- SD of 58 +/- 2.5 mm Hg to 74 +/- 11.5 mm Hg 5 hours after infusion; P = 0.006) and the alveolar-arterial difference for partial pressure of oxygen (PAO(2) - PaO(2) ) decreased in all patients, with a maximum effect achieved after 5 hours (from 49 +/- 3.3 mm Hg to 30 +/- 10.4 mm Hg; P = 0.003); even after 10 hours, PAO(2) - PaO(2) was still significantly reduced compared with baseline (P = 0.041). Oxygenation improved because of reduction in shunt fraction (from 41% +/- 3.1% to 25% +/- 4.5%; P < 0.001). Mean pulmonary artery pressure increased (from 20 +/- 5.2 mm Hg to 23 +/- 3.6 mm Hg; P = 0. 028), as did pulmonary vascular resistance (from 58 +/- 23 dyne/sec. cm(-5) to 115 +/- 56 dyne/sec. cm(-5); P = 0.012). Arterial blood pressure did not change significantly. Cardiac output decreased (from 10.6 +/- 2.2 L/min to 8.6 +/- 2.7 L/min; P = 0.008) and systemic vascular resistance increased (from 527 +/- 144 dyne/sec. cm(-5) to 729 +/- 222 dyne/sec. cm(-5); P = 0.037). Heart rate, central venous pressure, and pulmonary capillary wedge pressure remained unchanged.
  
  
  CONCLUSIONS
  Intravenous methylene blue improved hypoxemia and hyperdynamic circulation in patients with liver cirrhosis and severe hepatopulmonary syndrome.
authors.affiliation: Department of Internal Medicine 4, Intensive Care, University of Vienna, Allgemeines Krankenhaus, Waehringer Guertel 18-20, A-1090 Vienna, Austria. peter.schenk@akh-wien.ac.at
authors.forename: P
authors.initials: P
authors.lastname: Schenk
authors.forename: C
authors.initials: C
authors.lastname: Madl
authors.forename: S
authors.initials: S
authors.lastname: Rezaie-Majd
authors.forename: S
authors.initials: S
authors.lastname: Lehr
authors.forename: C
authors.initials: C
authors.lastname: Müller
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D002408:Catheters, Indwelling; D004791:Enzyme Inhibitors / Q000627:therapeutic use*; D005260:Female; D006162:Guanylate Cyclase / Q000037:antagonists & inhibitors*; D006439:Hemodynamics / Q000187:drug effects; D020065:Hepatopulmonary Syndrome / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D000860:Hypoxia / Q000188:drug therapy / Q000209:etiology; D007261:Infusions, Intra-Arterial; D008297:Male; D008751:Methylene Blue / Q000627:therapeutic use*; D008875:Middle Aged; D010100:Oxygen / Q000097:blood; D011659:Pulmonary Gas Exchange / Q000187:drug effects
chemical_list: D004791:Enzyme Inhibitors; D006162:Guanylate Cyclase; D010100:Oxygen; D008751:Methylene Blue