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Wedemire C, Samavat H, Newkirk M, Parker A. Treatment of refractory shock with vitamin B 12 : A narrative review. Nutr Clin Pract 2024; 39:356-365. [PMID: 38030578 DOI: 10.1002/ncp.11095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/17/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023] Open
Abstract
High-dose vitamin B12 is a potential treatment for patients with vasodilatory shock that is refractory to other therapies. Vasodilatory shock is characterized by low blood pressure and low systemic vascular resistance. Nitric oxide and hydrogen sulfide, two potential targets of high-dose vitamin B12 given as hydroxocobalamin, facilitate this syndrome. This review explores the relationship between high-dose vitamin B12 and hemodynamic outcomes in adults with vasodilatory shock and provides an update on the literature since a 2019 review on this topic. A literature search of studies published in the past 5 years was conducted in the CINAHL, PubMed, Cochrane, and EMBASE databases in May 2023. After assessing for eligibility, eight studies met this review's inclusion criteria. Seven of the eight studies reported decreased vasopressor requirements for part or all of the study samples after receiving a hydroxocobalamin infusion. However, not all patients responded to hydroxocobalamin. These findings are limited by patient selection and differences in the timing of vasopressor requirement and blood pressure outcome assessments. The current evidence is promising as to whether vitamin B12 , given as a hydroxocobalamin infusion, may improve hemodynamic outcomes in vasodilatory shock, but the evidence is of low quality. The use of hydroxocobalamin to treat refractory, vasodilatory shock remains investigative. Larger randomized controlled trials are required to elucidate the role of vitamin B12 in treating refractory, vasodilatory shock, including in conjunction with other alternative therapies such as methylene blue and corticosteroids.
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Affiliation(s)
- Courtney Wedemire
- Department of Dietitian Services, Abbotsford Regional Hospital, Abbotsford, British Columbia, Canada
| | - Hamed Samavat
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Newark, New Jersey, USA
| | - Melanie Newkirk
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Newark, New Jersey, USA
| | - Anna Parker
- Department of Clinical and Preventive Nutrition Sciences, School of Health Professions, Newark, New Jersey, USA
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Kumar N, Falkson SR, Lu SY, Dalia AA. Hydroxocobalamin Versus Methylene Blue: Still Unanswered and Needing a Change in Approach. J Cardiothorac Vasc Anesth 2024; 38:340-341. [PMID: 37973505 DOI: 10.1053/j.jvca.2023.08.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Nicolas Kumar
- Department of Anesthesia, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Samuel R Falkson
- Department of Anesthesia, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shu Yang Lu
- Department of Anesthesia, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesia, Pain Medicine, and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Suero OR, Park Y, Wieruszewski PM, Chatterjee S. Management of Vasoplegic Shock in the Cardiovascular Intensive Care Unit after Cardiac Surgery. Crit Care Clin 2024; 40:73-88. [PMID: 37973358 DOI: 10.1016/j.ccc.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Vasoplegic shock after cardiac surgery is characterized by hypotension, a high cardiac output, and vasodilation. Much of the understanding of this pathologic state is informed by the understanding of septic shock. Adverse outcomes and mortality are increased with vasoplegic shock. Early recognition and a systematic approach to its management are critical. The need for vasopressors to sustain an adequate blood pressure as well as pharmacologic adjuncts to mitigate the inflammatory inciting process are necessary. The rationale behind vasopressor escalation and consideration of adjuncts are discussed.
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Affiliation(s)
- Orlando R Suero
- Baylor St. Lukes Medical Center, 6720 Bertner Avenue, Room 0-520, Houston, TX 77030, USA
| | - Yangseon Park
- Baylor St. Lukes Medical Center, 6720 Bertner Avenue, Room 0-520, Houston, TX 77030, USA
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, RO_MB_GR_722PH, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA.
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Khandekar DA, Seelhammer TG, Mara KC, Stephens EH, Wittwer ED, Wieruszewski PM. Intraoperative Versus Postoperative Hydroxocobalamin for Vasoplegic Shock in Cardiothoracic Surgery. J Cardiothorac Vasc Anesth 2023; 37:2538-2545. [PMID: 37723020 DOI: 10.1053/j.jvca.2023.08.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVES Hydroxocobalamin inhibits nitric oxide pathways contributing to vasoplegic shock in patients undergoing cardiopulmonary bypass (CPB). The objective of this study was to evaluate the effect of intraoperative versus postoperative application of hydroxocobalamin for vasoplegic shock in patients undergoing CPB. DESIGN This was a historic cohort study. SETTING The study was conducted at a quaternary academic cardiovascular surgery program. PARTICIPANTS Adults undergoing cardiac surgery using CPB were participants in the study. INTERVENTIONS Hydroxocobalamin (5 g) intravenously over 15 minutes. MEASUREMENTS AND MAIN RESULTS The treatment groups were assigned based on the receipt location of hydroxocobalamin (ie, intensive care unit [ICU] versus operating room [OR]). The primary outcome was vasopressor-free days in the first 14 days after CPB. Of the 112 patients included, 37 patients received hydroxocobalamin in the OR and 75 in the ICU. Patients in the OR group were younger than those in the ICU group (57.5 v 63.9 years, p = 0.007), with statistically similar American Society of Anesthesiologists scores. The mean CPB duration was 3.4 hours in the OR group and 2.9 hours in the ICU group (p = 0.09). In both groups, the norepinephrine-equivalent dose of vasopressors at hydroxocobalamin was 0.27 µg/kg/min. Days alive and free of vasopressors were not different between the OR and ICU groups (estimated difference 0.48 [95% CI -1.76-2.72], p = 0.67). The odds of postoperative renal failure, mesenteric ischemia, ICU, hospital length of stay, and in-hospital mortality were also similar between groups. CONCLUSIONS A difference in vasopressor-free days after CPB was not found between patients who received hydroxocobalamin intraoperatively versus postoperatively for vasoplegic shock.
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Affiliation(s)
| | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
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Hiruy A, Ciapala S, Donaldson C, Wang L, Hohlfelder B. Hydroxocobalamin Versus Methylene Blue for the Treatment of Vasoplegic Shock Associated With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2023; 37:2228-2235. [PMID: 37586951 DOI: 10.1053/j.jvca.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/24/2023] [Accepted: 07/14/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES To compare changes in vasopressor requirements and hemodynamic responses after hydroxocobalamin or methylene blue administration for vasoplegic shock (VS). DESIGN Retrospective cohort analysis. SETTING Single-center, academic medical center. PATIENTS Cardiothoracic surgery adult patients. INTERVENTIONS Hydroxocobalamin or methylene blue. MEASUREMENTS The primary outcome was a change in vasopressor requirements over the first 24 hours (1, 3, 6, 12, and 24 hours) after hydroxocobalamin or methylene blue initiation. Secondary outcomes included changes in mean arterial pressure (MAP), systemic vascular resistance, and lactate. MAIN RESULTS A total of 120 adult patients who received hydroxocobalamin (n = 77) or methylene blue (n = 43) were included. Vasopressor requirements at baseline were 0.34 µg/kg/min (95% CI 0.28-0.4) norepinephrine equivalent (NEE) in the hydroxocobalamin group, and 0.59 µg/kg/min (95% CI 0.52-0.66) NEE in the methylene blue group; p < 0.001. Vasopressor requirements decreased significantly at each time point within each group (hour 1 mean [95% CI] NEE, hydroxocobalamin 0.27 µg/kg/min [0.21-0.33]; methylene blue 0.44 µg/kg/min [0.38-0.51]; p < 0.001). The mean MAP at baseline was 65 mmHg (95% CI 63-67) in the hydroxocobalamin group, and 57 mmHg (95% CI 54-59) in the methylene blue group; p < 0.001. The mean MAP increased significantly from baseline at each time point within each group (hour 1 mean [95% CI] hydroxocobalamin 73 mmHg [71-75]; methylene blue 67 mmHg [65-70]; p < 0.001). After adjusting for baseline characteristics, a significantly greater reduction in vasopressor requirements and an increase in MAP were noted in the hydroxocobalamin group compared with the methylene blue group. CONCLUSIONS Hydroxocobalamin was associated with a greater reduction in vasopressor requirements than methylene blue in treating VS associated with cardiopulmonary bypass.
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Affiliation(s)
- Aklil Hiruy
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH.
| | | | - Chase Donaldson
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, OH
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
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Brokmeier HM, Seelhammer TG, Nei SD, Gerberi DJ, Mara KC, Wittwer ED, Wieruszewski PM. Hydroxocobalamin for Vasodilatory Hypotension in Shock: A Systematic Review With Meta-Analysis for Comparison to Methylene Blue. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00241-0. [PMID: 37147207 DOI: 10.1053/j.jvca.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 05/07/2023]
Abstract
Hydroxocobalamin inhibits nitric oxide-mediated vasodilation, and has been used in settings of refractory shock. However, its effectiveness and role in treating hypotension remain unclear. The authors systematically searched Ovid Medline, Embase, EBM Reviews, Scopus, and Web of Science Core Collection for clinical studies reporting on adult persons who received hydroxocobalamin for vasodilatory shock. A meta-analysis was performed with random-effects models comparing the hemodynamic effects of hydroxocobalamin to methylene blue. The Risk of Bias in Nonrandomized Studies of Interventions tool was used to assess the risk of bias. A total of 24 studies were identified and comprised mainly of case reports (n = 12), case series (n = 9), and 3 cohort studies. Hydroxocobalamin was applied mainly for cardiac surgery vasoplegia, but also was reported in the settings of liver transplantation, septic shock, drug-induced hypotension, and noncardiac postoperative vasoplegia. In the pooled analysis, hydroxocobalamin was associated with a higher mean arterial pressure (MAP) at 1 hour than methylene blue (mean difference 7.80, 95% CI 2.63-12.98). There were no significant differences in change in MAP (mean difference -4.57, 95% CI -16.05 to 6.91) or vasopressor dosage (mean difference -0.03, 95% CI -0.12 to 0.06) at 1 hour compared to baseline between hydroxocobalamin and methylene blue. Mortality was also similar (odds ratio 0.92, 95% CI 0.42-2.03). The evidence supporting the use of hydroxocobalamin for shock is limited to anecdotal reports and a few cohort studies. Hydroxocobalamin appears to positively affect hemodynamics in shock, albeit similar to methylene blue.
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Affiliation(s)
| | | | - Scott D Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | | | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN.
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Blaha M, Blais M, Olson L. The Durability of Intravenous Hydroxocobalamin in Vasoplegia. Cureus 2023; 15:e38307. [PMID: 37255913 PMCID: PMC10226765 DOI: 10.7759/cureus.38307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/01/2023] Open
Abstract
Objectives Refractory distributive shock (vasoplegia) has been treated with intravenous (IV) hydroxocobalamin (B12), but its use is poorly characterized. The objective of this study was to quantify the duration of hemodynamic improvement after B12 administration. Materials and methods This was a retrospective chart review of adult patients who received IV B12 while on vasopressors in the intensive care unit. Patients were divided into two groups: responders (≥10% decrease in baseline vasopressor requirements within 60 minutes of B12 administration) and non-responders. Results A total of 16 patients were included, and five (31%) met the 'responder' criteria. The median time to respond was 15 minutes, and the response was maintained for a median of 210 minutes. The baseline median norepinephrine equivalent (NEE) rate was 32.9 mcg/min in responders and 24.7 mcg/min in non-responders. Responders' NEE requirements decreased to 16.7 mcg/min after 15 minutes and 14.8 mcg/min after 60 minutes. All responders and 10 (91%) non-responders were mechanically ventilated; both groups were mostly male (60% and 91%) and had a median age of 54 years and 58 years, respectively. A total of 4 (80%) responders and 10 (91%) non-responders died while hospitalized. IV B12 was administered as 5 g over 15 minutes in all but two patients (one responder and one non-responder), who each received 5 g of B12 over 360 minutes. Conclusion Vasopressor requirements decreased rapidly in 31% of patients after B12 administration and remained so for a median of 210 minutes.
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Affiliation(s)
| | - Meghan Blais
- Department of Pharmacy, Nebraska Medicine, Omaha, USA
| | - Logan Olson
- Department of Pharmacy, Nebraska Medicine, Omaha, USA
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Optimal, Early Postoperative Management of Cardiac Transplant and Durable Left Ventricular Assist Recipients. Curr Cardiol Rep 2022; 24:2023-2029. [PMID: 36327054 DOI: 10.1007/s11886-022-01823-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE OF REVIEW Summarize developments in the early postoperative care of patients undergoing cardiac transplantation or left ventricular assist device implantation. Provide a practical approach with personal insights to highly complex patients at risk for prolonged hospitalization. RECENT FINDINGS Advancements in technology allow for percutaneous mechanical circulatory support of both the right and left ventricles either isolated or combined via subclavian and neck vessels. Since the adult heart allocation system has been changed to reduce waitlist mortality, the use of temporary mechanical circulatory support has increased. This has influenced preoperative optimization by enabling ambulation and majorly changed postoperative strategy. New doors have been opened for a multidisciplinary approach to facilitate rapid weaning of inotropic medications, limitation of sedation, early liberation from mechanical ventilation, and mobilization. Individualized percutaneous mechanical circulatory support offers new possibilities for the early postoperative management of highly complex patients undergoing cardiac transplantation or durable left ventricular assist device implantation.
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Zhao CC, Zhai YJ, Hu ZJ, Huo Y, Li ZQ, Zhu GJ. Efficacy and safety of methylene blue in patients with vasodilatory shock: A systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:950596. [PMID: 36237547 PMCID: PMC9552293 DOI: 10.3389/fmed.2022.950596] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/01/2022] [Indexed: 12/03/2022] Open
Abstract
Background The role of methylene blue (MB) in patients with vasodilatory shock is unclear. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of MB in patients with vasodilatory shock. Methods We searched MEDLINE at PubMed, Embase, Web of Science, Cochrane, CNKI, CBM and Wanfang Medical databases for all observational and intervention studies comparing the effect of MB vs. control in vasodilatory shock patients. This study was performed in accordance with the PRISMA statement. There were no language restrictions for inclusion. Results A total of 15 studies with 832 patients were included. Pooled data demonstrated that administration of MB along with vasopressors significantly reduced mortality [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.34 to 0.85, P = 0.008; I 2 = 7%]. This benefit in mortality rate was also seen in a subgroup analysis including randomized controlled trials and quasi-randomized controlled trials. In addition, the vasopressor requirement was reduced in the MB group [mean difference (MD) -0.77, 95%CI -1.26 to -0.28, P = 0.002; I 2 = 80%]. Regarding hemodynamics, MB increased the mean arterial pressure, heart rate and peripheral vascular resistance. In respect to organ function, MB was associated with a lower incidence of renal failure, while in regards to oxygen metabolism, it was linked to reduced lactate levels. MB had no effect on the other outcomes and no serious side effects. Conclusions Concomitant administration of MB and vasopressors improved hemodynamics, decreased vasopressor requirements, reduced lactate levels, and improved survival in patients with vasodilatory shock. However, further studies are required to confirm these findings. Systematic review registration Identifier: CRD42021281847.
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Affiliation(s)
- Cong-Cong Zhao
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yu-Jia Zhai
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhen-Jie Hu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan Huo
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhi-Qiang Li
- Department of Intensive Care Unit, Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Gui-Jun Zhu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Bak MA, Smith JA, Murfin B, Chen Y. High-Dose Hydroxocobalamin for Refractory Vasoplegia Post Cardiac Surgery. Cureus 2022; 14:e28267. [PMID: 36039127 PMCID: PMC9395213 DOI: 10.7759/cureus.28267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
Administration of high-dose hydroxocobalamin, or vitamin B12, is an emerging, targeted rescue therapy for the treatment of refractory vasoplegic shock. This is an uncommon but potentially life-threatening complication following cardiac surgery and carries a poor prognosis, particularly when patients fail to respond to first-line therapy with catecholamine vasopressors. This study describes our experience in treating refractory vasodilatory shock following cardiac surgery with high-dose hydroxocobalamin. Administration of hydroxocobalamin in seven patients was associated with an improvement in mean arterial blood pressure or reduction in vasopressor requirements, which were both immediate and sustained throughout our observational period. No deaths or adverse effects attributable to hydroxocobalamin administration occurred in our cohort. Our observations show that high-dose hydroxocobalamin is a safe and effective rescue therapy in refractory vasoplegic shock post cardiopulmonary bypass (CPB).
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Determination of Methylene Blue and Its Metabolite Residues in Aquatic Products by High-Performance Liquid Chromatography-Tandem Mass Spectrometry. Molecules 2021; 26:molecules26164975. [PMID: 34443562 PMCID: PMC8401997 DOI: 10.3390/molecules26164975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 11/30/2022] Open
Abstract
A sensitive and reliable method was developed to determine methylene blue (MB) and its metabolite residues, including azure A (AZA), azure B (AZB), and azure C (AZC) in aquatic products by HPLC–MS/MS. The samples were extracted by acetonitrile and cleaned up by alumina-neutral (ALN) cartridges. The analytes were separated on a Sunfire C18 column (150 mm × 2.1 mm, 5 µm). The method was validated according to the European criteria of Commission Decision 2002/657/CE. Good linearity between 1–500 µg/L was obtained with correlation coefficients (R2) greater than 0.99. The limit of quantification (LOQ) was 1.0 µg/kg. The average recoveries at three levels of each compound (1, 5, and 10 µg/kg) were demonstrated to be in the range of 71.8–97.5%, with relative standard deviations (RSDs) from 1.05% to 8.63%. This method was suitable for the detection of methylene blue and its metabolite residues in aquatic products.
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