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ORIGINAL ARTICLE

Methylene blue administration in the treatment of the vasoplegic syndrome after cardiac surgery

José Carlos S. de AndradeI; Mário Lúcio Batista FilhoI; Paulo Roberto B ÉvoraII; José Roberto TavaresI; Ênio BuffoloI; Expedito E RibeiroI; Lélio A SilvaI; Carlos A TelesI; Antônia PetrizzoI; Vitor V Barata FilhoI; Renato DupratI

DOI: 10.1590/S0102-76381996000200009

ABSTRACT

The restoration of the systemic vascular resistance employing methylene blue (MB) in 6 patients after cardiac surgery with and without cardiopulmonary bypass is reported. All patients presented, during the immediate postoperative period, tachycardia, oligury, good peripheral perfusion and important systemic arterial hypotension not responsible to large doses of catecholamines infusion. The hemodynamic analysis, using the Swan-Ganz thermodilution technique, showed a profile compatible with vasoplegic syndrome, with the mean index of systemic vascular resistance of 868 dyne.s.cm5, similarly to the endotoxic shock this syndrome was assumed to be caused by nitric oxide synthase stimulation and release of nitric oxide (NO), by endothelial cells. Once released, NO stimulates solube guanylate cyclase, and thereby activates the production of cyclic guanosine 3',5' monophosphate (cGMP) resulting in relaxation. Methylene blue was administered to block the NO action by inhibiting the soluble guanylate cyclase at doses of 1.5 mg/kg during one hour intravenous infusion. Systemic vascular tone restoration (IRVS = 1693 dyne.s.cm5), with normal arterial pressure and clinical performance, were effective and fast, showing MB as a pharmacological tool able to reduce morbidity and mortality of the vasoplegic syndrome.

RESUMO

Relata-se a restauração da resistência vascular sistêmica com o uso do azul de metileno (AM) em pacientes submetidos a cirurgia cardíaca com e sem circulação extracorpórea. Todos os pacientes apresentaram no pós-operatório imediato quadro de taquicardia, oligúria, manutenção da perfusão periférica e importante hipotensão arterial sistêmica, retrataria a grandes doses de catecolaminas. As avaliações hemodinâmicas pela técnica de termodiluição com cateter de Swan-Ganz monstraram padrão compatível com síndrome vasoplégica, com índice de resistência vascular sistêmica média de 868 dina. s. cm5, sem resposta a drogas vasoativas. À semelhança do choque endotóxico, a síndrome foi interpretada como decorrente da estimulação da enzima óxido nítricosintetase com conseqüente formação de óxido nítrico (NO) pelas células endoteliais. Utilizou-se então AM, como bloqueador do NO no sistemaguanililciclase/guanino-monofosfatociclase, na dose de 1,5 mg/kg peso, em infusão intravenosa por uma hora. O restabelecimento do tônus vascular sistêmico (IRVS = 1693 dina. s. cm5) com normalização da pressão arterial e do quadro clínico, foi efetivo e rápido, mostrando ser o AM uma promissora droga na diminuição da morbi-mortalidade da síndrome vasoplégica.
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