title: Efficacy of methylene blue in an experimental model of calcium channel blocker-induced shock.
abstract: OBJECTIVE
  Calcium channel blocker poisonings account for a substantial number of reported deaths from cardiovascular drugs. Although supportive care is the mainstay of treatment, experimental therapies such as high-dose insulin-euglycemia and lipid emulsion have been studied in animal models and used in humans. In the most severe cases, even aggressive care is inadequate and deaths occur. In both experimental models and clinical cases of vasodilatory shock, methylene blue improves hemodynamic measures. It acts as a nitric oxide scavenger and inhibits guanylate cyclase that is responsible for the production of cyclic guanosine monophosphate (cGMP). Excessive cGMP production is associated with refractory vasodilatory shock in sepsis and anaphylaxis. The aim of this study is to determine the efficacy of methylene blue in an animal model of amlodipine-induced shock.
  
  
  METHODS
  Sprague-Dawley rats were anesthetized, ventilated, and instrumented for continuous blood pressure and pulse rate monitoring. The dose of amlodipine that produced death within 60 minutes was 17 mg/kg per hour (LD50). Rats were divided into 2 groups: amlodipine followed by methylene blue or amlodipine followed by normal saline solution, with 15 rats in each group. Rats received methylene blue at 2 mg/kg during 5 minutes or an equivalent amount of normal saline solution in 3 intervals from the start of the protocol: minutes 5, 30, and 60. The animals were observed for a total of 2 hours after the start of the protocol. Mortality risk and survival time were analyzed with Fisher's exact test and Kaplan-Meier survival analysis with the log rank test.
  
  
  RESULTS
  Overall, 1 of 15 rats (7%) in the saline solution-treated group survived to 120 minutes compared with 5 of 15 (33%) in the methylene blue-treated group (difference -26%; 95% confidence interval [CI] -54% to 0.3%). The median survival time for the normal saline solution group was 42 minutes (95% CI 28.1 to 55.9 minutes); for the methylene blue group, 109 minutes (95% CI 93.9 to 124.1 minutes). Pulse rate and mean arterial pressure (MAP) differences between groups were analyzed until 60 minutes. Pulse rate was significantly higher in the methylene blue-treated group beginning 25 minutes after the start of the amlodipine infusion (95% CI 30 to 113 minutes) that was analyzed until 60 minutes. MAP was significantly higher in the methylene blue-treated group starting 25 minutes after the amlodipine infusion (95% CI 2 to 30 minutes) that was analyzed until 60 minutes.
  
  
  CONCLUSIONS
  Methylene blue did not result in a significant difference in mortality risk. There was an increased pulse rate, MAP, and median survival time in the methylene blue group.
authors.affiliation: University of Pennsylvania Perelman School of Medicine, Department of Emergency Medicine, Philadelphia, PA. Electronic address: david.jang@uphs.upenn.edu.
authors.forename: David H
authors.initials: DH
authors.lastname: Jang
authors.affiliation: Albany Medical Center, Department of Emergency Medicine, Albany, NY.
authors.forename: Sean
authors.initials: S
authors.lastname: Donovan
authors.affiliation: New York University School of Medicine, Department of Emergency Medicine, New York, NY.
authors.forename: Lewis S
authors.initials: LS
authors.lastname: Nelson
authors.affiliation: Mt Sinai Roosevelt Hospital, Mt Sinai St Luke's Hospital, and the Icahn School of Medicine at Mt Sinai, New York, NY.
authors.forename: Theodore C
authors.initials: TC
authors.lastname: Bania
authors.affiliation: Division of Medical Toxicology, Department of Emergency Medicine, New York University School of Medicine, New York, NY.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Hoffman
authors.affiliation: Mt Sinai Roosevelt Hospital, Mt Sinai St Luke's Hospital, and the Icahn School of Medicine at Mt Sinai, New York, NY.
authors.forename: Jason
authors.initials: J
authors.lastname: Chu
mesh_terms: D017311:Amlodipine / Q000506:poisoning; D000818:Animals; D002121:Calcium Channel Blockers / Q000506:poisoning*; D004195:Disease Models, Animal; D016166:Free Radical Scavengers / Q000627:therapeutic use*; D006162:Guanylate Cyclase / Q000037:antagonists & inhibitors; D008751:Methylene Blue / Q000627:therapeutic use*; D017207:Rats, Sprague-Dawley; D012769:Shock / Q000139:chemically induced*
chemical_list: D002121:Calcium Channel Blockers; D016166:Free Radical Scavengers; D017311:Amlodipine; D006162:Guanylate Cyclase; D008751:Methylene Blue