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Katlan B. Methylene Blue in Metformin Intoxication: Not Just Rescue But Also Initial Treatment. Pediatr Emerg Care 2024:00006565-990000000-00415. [PMID: 38471766 DOI: 10.1097/pec.0000000000003152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
ABSTRACT Metformin (MTF) is a widely used oral antidiabetic medication. Regardless the reason, high doses of MTF cause lactic acidosis as a result of its effects on mitochondrial ATP production and no-mediated vascular smooth muscle relaxation. Metformin-associated lactic acidosis can be life-threatening despite all treatments. Methylene blue (MB) has the potential to reverse the toxic effects of MTF through its effects on both the mitochondrial respiratory chain and nitric oxide production. The use of MB in MTF intoxication has only been reported in a limited number of cases. Herein, we present a 16-year-old female patient who attempted suicide by ingesting high doses of MTF. Supportive treatments, such as vasopressor, inotropic treatments, and sodium bicarbonate, were started in the patient who developed fluid-resistant hypotension after pediatric intensive care unit admission. Because of rising lactate levels, Continuous renal replacement therapy (CRRT) was started immediately. Despite all treatments, hypotension and hyperlactatemia persisted; MB was given as a rescue therapy. Noticeable hemodynamic improvement was observed within 30 minutes of initiating MB infusion, allowing a gradual decrease in the doses of inotropic infusions within the first hour of therapy. Patient's cardiovascular support was discontinued on the second day, and she was discharged on the fifth day. We speculate that, considering the mechanisms of MTF toxicity and the mechanisms of action of MB, it is suggested that early administration of MB, not only as a rescue treatment but as the initial approach to MTF poisoning in combination with other treatments, may result in improved outcomes.
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Affiliation(s)
- Banu Katlan
- From the Departmant of Intensive Care Medicine, Mersin City Training and Research Center, Mersini Turkey
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2
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Hazekamp C, Schmitz Z, Scoccimarro A. Response to Comment on: "Methylene Blue-Induced Serotonin Toxicity: Case Files of the Medical Toxicology Fellowship at the New York City Poison Control Center". J Med Toxicol 2024; 20:70-71. [PMID: 38032430 PMCID: PMC10774489 DOI: 10.1007/s13181-023-00980-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Corey Hazekamp
- NYC H+H/Lincoln Department of Emergency Medicine, 234 E. 149Th Street, Bronx, NYNY, 10451, USA.
| | - Zach Schmitz
- New York City Poison Control Center, NYU Langone Toxicology Fellowship, New York, NY, USA
| | - Anthony Scoccimarro
- NYC H+H/Lincoln Department of Emergency Medicine, 234 E. 149Th Street, Bronx, NYNY, 10451, USA
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3
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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4
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Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila) 2022; 60:1205-1213. [DOI: 10.1080/15563650.2022.2131565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Jon B. Cole
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Samantha C. Lee
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Nathan M. Kunzler
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
| | | | - Brian E. Driver
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Travis D. Olives
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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5
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Narayan S, Petersen TL. Uncommon Etiologies of Shock. Crit Care Clin 2022; 38:429-441. [DOI: 10.1016/j.ccc.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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6
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The Roles of Antidotes in Emergency Situations. Emerg Med Clin North Am 2022; 40:381-394. [DOI: 10.1016/j.emc.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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7
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Abstract
Medications used to treat diabetes mellitus are heterogeneous, with widely differing safety profiles in therapeutic use and in overdose. Insulin overdose may produce severe and prolonged hypoglycemia. Sulfonylurea poisoning should be treated with octreotide, sparing intravenous dextrose where possible. Acute metformin overdose may lead to life-threatening acidosis with elevated lactate concentrations, which may require hemodialysis. Glucagon-like peptide 1 agonists and dipeptidyl peptidase 4 inhibitors are benign in overdose in diabetic patients but may produce profound hypoglycemia in nondiabetic patients. Euglycemic diabetic ketoacidosis may develop in critically ill patients taking sodium-glucose co-transporter 2 inhibitors.
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Affiliation(s)
- Kevin Baumgartner
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8072, St Louis, MO 63110, USA.
| | - Jason Devgun
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8072, St Louis, MO 63110, USA
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8
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St-Onge M. Cardiovascular Drug Toxicity. Crit Care Clin 2021; 37:563-576. [PMID: 34053706 DOI: 10.1016/j.ccc.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Managing unstable poisoned patients is often associated with clinician cognitive overload. This article summarizes the mechanisms of toxicity; clinical presentations; and the current evidence available for the treatment of cardiovascular drug toxicity due to calcium channel blockers, beta-blockers, cardiac glycosides, and sodium channel blockers. In addition, management approaches are proposed.
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Affiliation(s)
- Maude St-Onge
- CIUSSSCN, Optimal Health Practice Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec Research Centre, CHU de Québec - Université Laval, Faculty of Medicine, Université Laval, Centre Antipoison du Québec, 1270 Chemin Sainte-Foy, Pavillon Jeffrey-Hale, 3e étage, Québec G1S 2M4, Canada.
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9
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Mudan A, Lebin JA. Response to "The Mechanisms Underlying Methylene Blue-Mediated Attenuation of Nitric Oxide-induced Vasodilatation". J Emerg Med 2021; 60:680. [PMID: 34016380 DOI: 10.1016/j.jemermed.2020.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/22/2020] [Indexed: 10/21/2022]
Affiliation(s)
- Anita Mudan
- Department of Emergency Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California; California Poison Control System, San Francisco Division at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Jacob A Lebin
- Department of Emergency Medicine, University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California; California Poison Control System, San Francisco Division at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
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10
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Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review. Crit Care Med 2021; 49:838-857. [PMID: 33653974 DOI: 10.1097/ccm.0000000000004893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications. DATA SOURCES A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane). STUDY SELECTION Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications. DATA EXTRACTION Data from the relevant publications were reviewed, summarized and the information synthesized. DATA SYNTHESIS This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions. CONCLUSION Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.
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11
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Taccone FS, Gardette M, Creteur J, Brasseur A, Lorent S, Grimaldi D. Hemoadsorption to treat severe iatrogenic intoxication with Patent Blue: a case report. J Med Case Rep 2021; 15:63. [PMID: 33557948 PMCID: PMC7870281 DOI: 10.1186/s13256-020-02657-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 12/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background Intoxication with Patent Blue V [sodium compound of (diethylamino-4-phenyl)(hydroxy-5-disulfo-2,4-phenyl) methanol] can lead to high levels of methemoglobin and metabolic acidosis. In severe cases and if not rapidly eliminated from the plasma, this can lead to multiple organ failure and death. Case report A 27-year-old Asian woman (original from Vietnam) was admitted after ecstasy intoxication resulting in multi-organ failure (acute respiratory distress syndrome, metabolic acidosis, capillary leakage syndrome, renal failure, shock refractory to standard resuscitation). As a consequence, continuous renal replacement therapy and veno-venous extracorporeal membrane oxygenation were started. Methylene blue administration to reverse vasoplegia was decided, but unfortunately, Patent Blue V was erroneously administered, resulting in a severe clinical picture of methemoglobinemia and tissue hypoxia. As a therapeutic intervention, CytoSorb hemoadsorption was initiated, and rapid and significant reduction in plasma methemoglobin, accompanied by improved hemodynamics and normalization in plasma lactate levels, was observed. Conclusions This is the first case describing the application of CytoSorb hemoadsorption in a patient with ecstasy intoxication complicated by iatrogenic administration of Patent Blue V. There is a potential role for CytoSorb in drug intoxication, which needs to be confirmed in larger series.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Mickael Gardette
- Department of Intensive Care Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070, Brussels, Belgium
| | - Alexandre Brasseur
- Department of Intensive Care Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070, Brussels, Belgium
| | - Sophie Lorent
- Department of Pharmacy, Free University of Brussels, Brussels, Belgium
| | - David Grimaldi
- Department of Intensive Care Erasme Hospital, Free University of Brussels, Route de Lennik 808, 1070, Brussels, Belgium
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12
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Abstract
This article examines, using an organ-systems based approach, rapid diagnosis, resuscitation, and critical care management of the crashing poisoned patient in the emergency department. The topics discussed in this article include seizures and status epilepticus, respiratory failure, cardiovascular collapse and mechanical circulatory support, antidotes and drug-specific therapies, acute liver failure, and extracorporeal toxin removal.
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Affiliation(s)
- Aaron Skolnik
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Jessica Monas
- Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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13
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Kuan IHS, Savage RL, Duffull SB, Walker RJ, Wright DFB. The Association between Metformin Therapy and Lactic Acidosis. Drug Saf 2020; 42:1449-1469. [PMID: 31372935 DOI: 10.1007/s40264-019-00854-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is increasing evidence to suggest that therapeutic doses of metformin are unlikely to cause lactic acidosis. The aims of this research were (1) to formally evaluate the association between metformin therapy and lactic acidosis in published case reports using two causality scoring systems, (2) to determine the frequency of pre-existing independent risk factors in published metformin-associated lactic acidosis cases, (3) to investigate the association between risk factors and mortality in metformin-associated lactic acidosis cases, and (4) to explore the relationship between prescribed metformin doses, elevated metformin plasma concentrations and the development of lactic acidosis in cases with chronic renal impairment. METHODS A systematic review was conducted to identify metformin-associated lactic acidosis cases. Causality was assessed using the World Health Organisation-Uppsala Monitoring Centre system and the Naranjo adverse drug reaction probability scale. Compliance to dosing guidelines was investigated for cases with chronic renal impairment as well as the association between steady-state plasma metformin concentrations prior to admission. RESULTS We identified 559 metformin-associated lactic acidosis cases. Almost all cases reviewed (97%) presented with independent risk factors for lactic acidosis. The prescribed metformin dose exceeded published guidelines in 60% of cases in patients with impaired kidney function. Metformin steady-state plasma concentrations prior to admission were predicted to be below the proposed upper limit of the therapeutic range of 5 mg/L. CONCLUSIONS Almost all cases of metformin-associated lactic acidosis reviewed presented with independent risk factors for lactic acidosis, supporting the suggestion that metformin plays a contributory role. The prescribed metformin dose, on average, exceeded the dosing recommendations by 1000 mg/day in patients with varying degrees of renal impairment but the predicted pre-admission plasma concentrations did not exceed the therapeutic range.
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Affiliation(s)
- Isabelle H S Kuan
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Ruth L Savage
- New Zealand Pharmacovigilance Centre, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Stephen B Duffull
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand
| | - Robert J Walker
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Daniel F B Wright
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, New Zealand.
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14
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Tchen S, Sullivan JB. Clinical utility of midodrine and methylene blue as catecholamine-sparing agents in intensive care unit patients with shock. J Crit Care 2020; 57:148-156. [PMID: 32145658 DOI: 10.1016/j.jcrc.2020.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/29/2020] [Accepted: 02/17/2020] [Indexed: 02/07/2023]
Abstract
Shock is common in the intensive care unit, affecting up to one third of patients. Treatment of shock is centered upon managing hypotension and ensuring adequate perfusion via administration of fluids and catecholamine vasopressors. Due to the risks associated with catecholamine vasopressors, interest has grown in using catecholamine-sparing agents such as midodrine and methylene blue. Midodrine is an orally administered alpha-1 adrenergic agonist while methylene blue is an intravenously administered blue dye used to restore vascular tone and increase blood pressure. Separate MEDLINE, Scopus, and Embase database searches were conducted to assess literature revolving around these agents. Examples of search terms included "midodrine", "methylene blue", "critically ill", "shock", and "catecholamine-sparing." Several studies have evaluated their use in patients with shock and found potential benefits in terms of causing significant elevations in blood pressure and hastening catecholamine vasopressor discontinuation with few adverse effects; however, robust evidence is lacking for these off-label indications. Because of the variety of dosing strategies used and the incongruences between patient populations, it is also challenging to define finite recommendations. This review aims to summarize current evidence for the use of midodrine and methylene blue as catecholamine-sparing agents in critically ill patients with resolving or refractory shock.
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Affiliation(s)
- Stephanie Tchen
- Froedtert Hospital, 9200 W Wisconsin Ave, Milwaukee, WI 53226, United States of America.
| | - Jesse B Sullivan
- Fairleigh Dickinson University School of Pharmacy & Health Sciences, Pharmacy Practice, 230 Park Ave, M-SP1-01, Florham Park, NJ 07932, United States of America.
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15
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Lecor PA, Touré B, Moreau N, Braud A, Dieb W, Boucher Y. Could methylene blue be used to manage burning mouth syndrome? A pilot case series. JOURNAL OF ORAL MEDICINE AND ORAL SURGERY 2020. [DOI: 10.1051/mbcb/2020032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective: Burning mouth syndrome is a disabling condition of complex pathophysiology characterized by spontaneous pain felt in the oral mucosa in the absence of evident mucosal lesions which lacks efficient treatments to this day. The purpose of this study was to demonstrate the efficacy of methylene blue in the management of burning mouth syndrome. Methods: The study was conducted at the dental clinic of the Anta Diop University and Newtown dental clinic of Dakar, Senegal. A solution of methylene blue as a mouth-rinse (0.5%) was applied for 5 minutes in five patients satisfying the ICHD-3 diagnostic criteria for burning mouth syndrome. This procedure was repeated every 6 hours 3 times per 24h, during 7 days. Using numeric rating scale, pain severity was assessed as the mean pain felt during the last day of application. Results: After 7 days, the pain was significantly reduced by two-thirds and almost absent at 3 and 6 months follow-up. No secondary effects of the use of methylene blue were observed. Putative mechanisms of action and potential implications for treatment are discussed. Conclusion: Methylene blue is an old compound but a novel topical therapy that could prove beneficial in the management of burning mouth syndrome.
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16
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Boley SP, Mackenzie RB, LeRoy JM, Engebretsen KM, Stellpflug SJ. Development and Feasibility of a Porcine Model of Amlodipine Toxicity. J Med Toxicol 2019; 16:61-66. [PMID: 31385194 DOI: 10.1007/s13181-019-00721-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Toxicity related to calcium-channel blockers remains a significant cause of morbidity and mortality. Amlodipine-induced shock is unique in that its mechanism of action is thought to occur in part via the release of nitric oxide (NO) in the peripheral vasculature. Specific therapeutic interventions, including methylene blue (an NO scavenger), have been suggested, but efficacy studies are severely limited. To facilitate a larger porcine study into the effect of various interventions on amlodipine toxicity, we undertook this model development and feasibility study. METHODS Intravenous amlodipine was prepared by dissolving commercially obtained amlodipine tablets in dimethylsulfoxide. The concentration of the drug was verified using ultraviolet spectroscopy. We administered this solution to three animals in order to determine a toxic dose, capable of facilitating a two-arm study of amlodipine toxicity. RESULTS The first pig died rapidly after the bolus infusion. The second pig developed mild toxicity, but the dissolution of the plastic tubing by the solvent and subsequent leakage limited the interpretability of the result. The third animal developed expected toxicity with an infusion rate between 2.0 and 5.5 mg/kg/h. CONCLUSION This study demonstrates a potentially repeatable model of amlodipine-induced toxic shock using intravenous administration of amlodipine and several methodological considerations for researchers undertaking similar work.
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Affiliation(s)
- Sean P Boley
- Department of Emergency Medicine, United Hospital, St. Paul, MN, USA
| | | | - Jenna M LeRoy
- Department of Emergency Medicine, Regions Hospital, St. Paul, MN, USA
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17
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Procopio GL, Patel R, Gupta A. Clinical Pearls in Medical Toxicology: Updates Ranging From Decontamination to Elimination. J Pharm Pract 2019; 32:339-346. [PMID: 31291840 DOI: 10.1177/0897190019854565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Such as any field of medicine, it is imperative to stay current with the latest advances and treatment modalities in toxicology. With the absence of rigorous randomized controlled trials, many updated guidelines are created by expert consensus and/or case reports and clinical experience. Over the past 10 years, there have been several changes in the management of drug overdoses in light of new data available. Although this is not a comprehensive review of all available antidotes, this article will focus on several important interventions including the use of gastrointestinal decontamination, hyperinsulinemic-euglycemic therapy, methylene blue, intravenous lipid emulsion, hemodialysis, and extracorporeal membrane oxygenation.
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Affiliation(s)
- Gabrielle L Procopio
- 1 Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA.,2 Department of Emergency Medicine at the Hackensack Meridian School of Medicine, Seton Hall University, Nutley, NJ, USA
| | - Ruchi Patel
- 1 Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Amit Gupta
- 1 Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA.,3 Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, NJ, USA
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18
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Nafea OE, Hassan HA. Comparative effectiveness of methylene blue versus intravenous lipid emulsion in a rodent model of amlodipine toxicity. Clin Toxicol (Phila) 2019; 57:784-789. [PMID: 30729824 DOI: 10.1080/15563650.2018.1560461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Context: Calcium channel blocker (CCB) poisonings are the leading cause of death from cardiovascular medication-related overdoses. Current treatments (calcium salts, vasopressors, inotropes) are often insufficient. Intravenous lipid emulsion (ILE) and methylene blue (MB) show promise in treating CCB overdoses unresponsive to conventional therapy. Objective: To compare the effectiveness of MB versus ILE in a rodent model of amlodipine (AML) poisoning with survival as the primary outcome and hemodynamic parameters as secondary outcomes. Materials and methods: Sixty-four adult male albino rats were anesthetized and cannulated for non-invasive hemodynamic measurement. Rats received amlodipine intraperitoneally (42 mg/kg). We then divided the rats into four groups: AML only without antidote, AML followed by ILE (24.8 mL/kg over 10 min), AML followed by normal saline (an equivalent volume of ILE), and AML followed by IV MB (2 mg/kg over 5 min). They received study treatments at 5, 30, and 60 minutes from the start of the protocol and with observation for 2 hours. Results: Survival time in ILE group was greater than in the control and NS groups. Differences between ILE and MB and between MB and NS were not significant. Hemodynamic parameters significantly increased in ILE group compared to the MB group at the 30, 60 and 120 min assessments but not after induction of AML poisoning and at 5 min assessment. Conclusions: Survival was greatest in rats treated with ILE. Both MB and NS had little effect on survival when compared to control animals. Both ILE and MB improved hemodynamics.
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Affiliation(s)
- Ola E Nafea
- a Faculty of Medicine, Department of Forensic Medicine and Clinical Toxicology, Zagazig University , Zagazig , Egypt
| | - Heba A Hassan
- b Faculty of Medicine, Department of Clinical Pharmacology, Zagazig University , Zagazig , Egypt
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19
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Piel S, Ehinger JK, Chamkha I, Frostner EÅ, Sjövall F, Elmér E, Hansson MJ. Bioenergetic bypass using cell-permeable succinate, but not methylene blue, attenuates metformin-induced lactate production. Intensive Care Med Exp 2018; 6:22. [PMID: 30069806 PMCID: PMC6070446 DOI: 10.1186/s40635-018-0186-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/09/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Metformin is the most common pharmacological treatment for type 2 diabetes. It is considered safe but has been associated with the development of lactic acidosis under circumstances where plasma concentrations exceed therapeutic levels. Metformin-induced lactic acidosis has been linked to the drug's toxic effect on mitochondrial function. Current treatment strategies aim to remove the drug and correct for the acidosis. With a mortality of 20%, complementary treatment strategies are needed. In this study, it was investigated whether targeting mitochondria with pharmacological agents that bypass metformin-induced mitochondrial dysfunction can counteract the energetic deficit linked to toxic doses of metformin. METHODS The redox agent methylene blue and the cell-permeable succinate prodrug NV118 were evaluated by measuring mitochondrial respiration and lactate production of human platelets exposed to metformin and co-treated with either of the two pharmacological bypass agents. RESULTS The cell-permeable succinate prodrug NV118 increased mitochondrial respiration which was linked to phosphorylation by the ATP-synthase and alleviated the increase in lactate production induced by toxic doses of metformin. The redox agent methylene blue, in contrast, failed to mitigate the metformin-induced changes in mitochondrial respiration and lactate generation. CONCLUSIONS The cell-permeable succinate prodrug NV118 bypassed the mitochondrial dysfunction and counteracted the energy deficit associated with toxic doses of metformin. If similar effects of NV118 prove translatable to an in vivo effect, this pharmacological strategy presents as a promising complementary treatment for patients with metformin-induced lactic acidosis.
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Affiliation(s)
- Sarah Piel
- Department of Clinical Sciences Lund, Mitochondrial Medicine, Lund University, BMC A13, 22184 Lund, Sweden
- NeuroVive Pharmaceutical AB, Medicon Village, 22381 Lund, Sweden
| | - Johannes K. Ehinger
- Department of Clinical Sciences Lund, Mitochondrial Medicine, Lund University, BMC A13, 22184 Lund, Sweden
- NeuroVive Pharmaceutical AB, Medicon Village, 22381 Lund, Sweden
- Department of Clinical Sciences Lund, Otorhinolaryngology, Head and Neck Surgery, Lund University, Skane University Hospital, 22185 Lund, Sweden
| | - Imen Chamkha
- Department of Clinical Sciences Lund, Mitochondrial Medicine, Lund University, BMC A13, 22184 Lund, Sweden
- NeuroVive Pharmaceutical AB, Medicon Village, 22381 Lund, Sweden
| | - Eleonor Åsander Frostner
- Department of Clinical Sciences Lund, Mitochondrial Medicine, Lund University, BMC A13, 22184 Lund, Sweden
- NeuroVive Pharmaceutical AB, Medicon Village, 22381 Lund, Sweden
| | - Fredrik Sjövall
- Department of Clinical Sciences Lund, Mitochondrial Medicine, Lund University, BMC A13, 22184 Lund, Sweden
- Department of Clinical Sciences Lund, Intensive Care and Perioperative Medicine, Lund University, Skane University Hospital, 20502 Malmö, Sweden
| | - Eskil Elmér
- Department of Clinical Sciences Lund, Mitochondrial Medicine, Lund University, BMC A13, 22184 Lund, Sweden
- NeuroVive Pharmaceutical AB, Medicon Village, 22381 Lund, Sweden
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Lund University, Skane University Hospital, 22185 Lund, Sweden
| | - Magnus J. Hansson
- Department of Clinical Sciences Lund, Mitochondrial Medicine, Lund University, BMC A13, 22184 Lund, Sweden
- NeuroVive Pharmaceutical AB, Medicon Village, 22381 Lund, Sweden
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Chan BS, Becker T, Chiew AL, Abdalla AM, Robertson TA, Liu X, Roberts MS, Buckley NA. Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome. J Med Toxicol 2018; 14:100-103. [PMID: 29134498 PMCID: PMC6013734 DOI: 10.1007/s13181-017-0637-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Management of severe vasoplegic shock in overdose can be very challenging. We describe a case of severe refractory vasodilatory shock in poisoning where methylene blue (MB) was used with success. However, the patient subsequently developed severe Serotonin Syndrome (SS) as a result of an interaction between serotonergic drugs and MB. CASE REPORT A 15-year-old male developed severe vasoplegic shock 1.5 hours after overdosing on several different medications including quetiapine slow release, quetiapine immediate release, desvenlafaxine slow release, venlafaxine, amlodipine, ramipril, fluoxetine, promethazine and lithium. His vasoplegic shock was resistant to high doses of noradrenaline and vasopressin. MB was administered 6.5 hours post ingestion and within 1 hour there was an improvement in his hemodynamic status and reduction of catecholamine requirements. Twelve hours post ingestion, he developed severe Serotonin Syndrome that lasted 5 days as a result of interaction between MB, a reversible monoamine oxidase inhibitor (MAO-I), and the antidepressants taken in overdose. MB had a calculated half-life of 38 hours. CONCLUSION MB is a useful additional strategy for severe drug induced vasodilatory shock and may be potentially life-saving. Clinicians should be aware that it can interact with other drugs and cause life-threatening Serotonin Syndrome. Lower doses or shorter durations may be wise in patients at risk of this interaction.
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Affiliation(s)
- Betty S Chan
- Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia.
| | - Therese Becker
- Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Angela L Chiew
- Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Ahmed M Abdalla
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Tom A Robertson
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Xin Liu
- Therapeutics Research Centre, Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Australia
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
- Therapeutics Research Centre, Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Australia
| | - Nicholas A Buckley
- Department of Clinical Pharmacology, University of Sydney, Sydney, New South Wales, Australia
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Heme oxygnease-1 induction by methylene blue protects RAW264.7 cells from hydrogen peroxide-induced injury. Biochem Pharmacol 2018; 148:265-277. [PMID: 29309766 DOI: 10.1016/j.bcp.2018.01.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 01/04/2018] [Indexed: 01/23/2023]
Abstract
Although methylene blue (MB) has showed strong antioxidant effect, its effect related with heme oxygenase-1 (HO-1) is still unclear. Thus, we investigated the effects of MB on HO-1 protein content and enzyme activity, and its protective effect against hydrogen peroxide (H2O2)-induced oxidative damage in RAW264.7 macrophage. The cell viability and the release of lactate dehydrogenase of RAW264.7 were determined. The mitochondrial functions were valuated through these indexes: content of adenosine triphosphate, superoxide dismutase, concentration of reactive oxygen species and mitochondrial membrane potential. Meanwhile, high content screening tested generation of ROS, MMP and intracellular concentration of calcium ion. qRT-PCR valuated macrophage phenotype markers expression. Lastly, flow cytometry and caspase-3 detection analyzed RAW264.7 apoptosis. Our data showed that (1) Both pretreatment and posttreatment of MB increased HO-1 protein content and enzyme activity; (2) MB rescued cells from H2O2-induced mitochondrial dysfunction; (3) High content screening revealed that MB alleviated the changes including generation of reactive oxygen species, mitochondrial membrane potential and intracellular concentration of calcium ion in H2O2 exposed RAW264.7; (4) MB attenuated H2O2-induced apoptosis; (5) MB pretreatment decreased the expression of M1 macrophage markers (Tnf and Nos2) while increasing the expression of M2 macrophage markers (Mrc1 and Il10); (6) The beneficial effect of MB was abolished by zinc protoporphyrin IX (HO-1 activity inhibitor) or HO-1 siRNA. In summary, MB protects RAW264.7 cells from H2O2-induced injury through up-regulation HO-1.
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Severe Undifferentiated Vasoplegic Shock Refractory to Vasoactive Agents Treated with Methylene Blue. Case Rep Crit Care 2017; 2017:8747326. [PMID: 29098094 PMCID: PMC5642875 DOI: 10.1155/2017/8747326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 08/27/2017] [Indexed: 11/17/2022] Open
Abstract
Methylene blue is a phenothiazine-related heterocyclic aromatic molecule presently used in the treatment of methemoglobinemia. Recently, it has been implicated in the treatment of severe refractory vasoplegic shock caused by anaphylaxis, sepsis, or postcardiopulmonary bypass. We present a case of a 27-year-old male with profound vasoplegic shock of unknown etiology which was refractory to vasopressors who responded within hours to a single dose of methylene blue. Additionally, we review the evidence of methylene blue's role in the treatment of shock. This case illustrates a diagnostic approach and treatment options in the setting of undifferentiated vasodilatory shock and outlines a new and emerging role for methylene blue in this clinical setting.
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St-Onge M, Anseeuw K, Cantrell FL, Gilchrist IC, Hantson P, Bailey B, Lavergne V, Gosselin S, Kerns W, Laliberté M, Lavonas EJ, Juurlink DN, Muscedere J, Yang CC, Sinuff T, Rieder M, Mégarbane B. Experts Consensus Recommendations for the Management of Calcium Channel Blocker Poisoning in Adults. Crit Care Med 2017; 45:e306-e315. [PMID: 27749343 PMCID: PMC5312725 DOI: 10.1097/ccm.0000000000002087] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide a management approach for adults with calcium channel blocker poisoning. DATA SOURCES, STUDY SELECTION, AND DATA EXTRACTION Following the Appraisal of Guidelines for Research & Evaluation II instrument, initial voting statements were constructed based on summaries outlining the evidence, risks, and benefits. DATA SYNTHESIS We recommend 1) for asymptomatic patients, observation and consideration of decontamination following a potentially toxic calcium channel blocker ingestion (1D); 2) as first-line therapies (prioritized based on desired effect), IV calcium (1D), high-dose insulin therapy (1D-2D), and norepinephrine and/or epinephrine (1D). We also suggest dobutamine or epinephrine in the presence of cardiogenic shock (2D) and atropine in the presence of symptomatic bradycardia or conduction disturbance (2D); 3) in patients refractory to the first-line treatments, we suggest incremental doses of high-dose insulin therapy if myocardial dysfunction is present (2D), IV lipid-emulsion therapy (2D), and using a pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block without significant alteration in cardiac inotropism (2D); 4) in patients with refractory shock or who are periarrest, we recommend incremental doses of high-dose insulin (1D) and IV lipid-emulsion therapy (1D) if not already tried. We suggest venoarterial extracorporeal membrane oxygenation, if available, when refractory shock has a significant cardiogenic component (2D), and using pacemaker in the presence of unstable bradycardia or high-grade arteriovenous block in the absence of myocardial dysfunction (2D) if not already tried; 5) in patients with cardiac arrest, we recommend IV calcium in addition to the standard advanced cardiac life-support (1D), lipid-emulsion therapy (1D), and we suggest venoarterial extracorporeal membrane oxygenation if available (2D). CONCLUSION We offer recommendations for the stepwise management of calcium channel blocker toxicity. For all interventions, the level of evidence was very low.
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Affiliation(s)
- Maude St-Onge
- 1Centre antipoison du Québec, CHU de Quebec Research Center, Population Health and Optimal Health Practices, Department of Family Medicine and Emergency medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Ville de Québec, Quebec, Canada. 2Department of Emergency Medicine, ZNA Stuivenberg, Antwerp, Belgium 3School of Pharmacy, University of California, San Francisco, San Francisco, CA. 4Heart and Vascular Institute, Penn State Hershey Medical Center, Hershey, PA. 5Department of Intensive Care, Cliniques St-Luc, Université Catholique de Louvain, Leuven, Belgium. 6Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada. 7Department of Medical Biology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada. 8Centre antipoison du Québec, Department of Medicine, McGill University, Department of Emergency Medicine, McGill University Health Centre, Montreal, QC, Canada. 9Division of Medical Toxicology, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC. 10Quebec Poison Centre, Department of Emergency Medicine, McGill University Health Centre, Montreal, QC, Canada. 11Department of Emergency Medicine, Denver Health and Hospital Authority, University of Colorado, Boulder, CO. 12Ontario Poison Centre, Sunnybrook Health Sciences Centre, Departments of Medicine and Pediatrics, University of Toronto, Toronto, ON, Canada. 13Kingston General Hospital, Queens' University, Kingston, ON, Canada. 14Institute of Environmental & Occupational Health Sciences, School of Medicine, National Yang-Ming University, Taipei, Taiwan. 15Division of Clinical Toxicology & Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. 16Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, and Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. 17Department of Paediatrics, Physiology and Pharmacology and Medicine, Western University, London, ON, Canada. 18Department of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM U1144, Paris-Diderot University, Paris, France
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Harding SA, Hoffman RS, Jang DH. In response to: "A systematic analysis of methylene blue for drug-induced shock". Clin Toxicol (Phila) 2017; 55:227. [PMID: 28073321 DOI: 10.1080/15563650.2016.1271884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Stephen A Harding
- a Division of Medical Toxicology, Ronald O Perelman Department of Emergency Medicine , New York University , New York , NY , USA
| | - Robert S Hoffman
- a Division of Medical Toxicology, Ronald O Perelman Department of Emergency Medicine , New York University , New York , NY , USA
| | - David H Jang
- b Division of Medical Toxicology and Critical Care Medicine , Department of Emergency Medicine at the University of Pennsylvania Perelman School of Medicine , Philadelphia , PA , USA
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