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CARDIOVASCULAR ANESTHESIA

The Effect of Methylene Blue on the Hemodynamic Changes During Ischemia Reperfusion Injury in Orthotopic Liver Transplantation

Heike Koelzow, MD, FRCA^*, Jacqueline A. Gedney, MRCP(UK), FRCA, Janos Baumann, MD, EDICM^*, Nicola J. Snook, FRCA^*, and Mark C. Bellamy, MA, FRCA^*

*St James’s University Hospital, Beckett Street, Leeds; and James Cook University Hospital, Middlesbrough, UK

Address correspondence and reprint requests to Dr. Mark C. Bellamy, Intensive Care Unit, St. James’s University Hospital, Beckett St., Leeds LS9 7TF, UK. Address e-mail to mark{at}livertransplant org.uk.

After graft reperfusion in orthotopic liver transplantation (OLT), ischemia reperfusion syndrome (IRS) is characterized by persistent hypotension with a low systemic vascular resistance. Methylene blue (MB) has been used as a vasopressor in sepsis and acute liver failure. We investigated the effect of MB on IRS during OLT. Thirty-six patients undergoing elective OLT were randomized to receive either a bolus of MB 1.5 mg/kg before graft reperfusion, or normal saline (placebo). We recorded hemodynamic variables, postoperative liver function tests, and time to hospital discharge. Blood samples were analyzed for arterial lactate concentration, cyclic 3',5'-monophosphate, and plasma nitrite/nitrate concentrations. The MB group had higher mean arterial pressure (P = 0.035), higher cardiac index (P = 0.04), and less epinephrine requirement (P = 0.02). There was no difference in systemic vascular resistance or central venous pressure. Serum lactate levels were lower at 1 h after reperfusion in MB patients, suggesting better tissue perfusion (P = 0.03). In the presence of MB, there was a reduction in cyclic 3',5'-monophosphate (P < 0.001), but not plasma nitrites. Postoperative liver function tests and time to hospital discharge were the same in both groups. MB attenuated the hemodynamic changes of IRS in OLT acting via guanylate cyclase inhibition.

IMPLICATIONS: Methylene blue attenuates the hemodynamic changes of the ischemia reperfusion syndrome in liver transplantation, and this effect involves guanylate cyclase inhibition.

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