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Francisco Chacón-Lozsán: Limited Evidence Methylene Blue in Vasoplegic Shock
Francisco Chacón-Lozsán/Linkedin,Shannon M. Fernando/Linkedin
Apr 26, 2026, 17:02

Francisco Chacón-Lozsán: Limited Evidence Methylene Blue in Vasoplegic Shock

Francisco Chacón-Lozsán, Fellow at World Extreme Medicine, Member of European Society of Intensive Care Medicine (ESICM) and American College of Cardiology, shared a post on LinkedIn about a recent article by Shannon M. Fernando published in Journal of Critical Care:

”Methylene blue in septic shock: miracle, myth… or misunderstood tool?

We all know the scenario:

  • Refractory vasoplegic shock
  • Escalating norepinephrine
  • Vasopressin, steroids… still hypotensive

At some point, the question comes:

Should we use methylene blue?

Mechanism

Septic shock equals NO-driven vasoplegia

Methylene blue acts by:

  • Inhibiting nitric oxide synthase (NOS)
  • Blocking soluble guanylate cyclase

Reducing cGMP

Restoring vascular tone

A true catecholamine-sparing strategy

What does the evidence say?

Reality check:

Use in practice is rare (0.5percent of septic shock patients)

Often used as late salvage therapy

Dosing strategies equals highly variable

But RCT signals are interesting:

  • Reduced Vasopressor duration
  • Shorter ICU / hospital length of stay
  • Possible reduction mortality (low certainty)

Evidence is promising… but still weak

The clinical dilemma

Timing is everything:

  • Early use -potential physiologic benefit
  • Late use – often too late to change trajectory
  • Current practice is probably backwards

What about safety?

Potential concerns:

Serotonin syndrome (with SSRIs)

Pulmonary vasoconstriction

G6PD-related hemolysis

Interference with pulse oximetry

Most serious effects seen with high doses

Take-home message

Methylene blue is not a ‘magic drug’

but it may be a physiology-driven adjunct in vasoplegic shock

The real questions are:

  • Who benefits?
  • When to give it?
  • At what dose?

Where we’re heading

Ongoing trials (e.g., BLUSH trial) will clarify:

  • Early vs late use
  • Optimal dosing strategy
  • True impact on mortality

This could redefine vasoplegic shock management

Clinical reflection

Next time you face refractory shock, ask:

  • Is this still ‘fluid plus catecholamine problem’…
  • or already a NO-mediated vasoplegia problem?

Title: What every intensivist should know about…methylene blue in septic shock

Authors: Shannon M. Fernando, Karim Soliman, Alexandre Tran, Salmaan Kanji, Bram Rochwerg

Francisco Chacón-Lozsán: Limited Evidence Methylene Blue in Vasoplegic Shock

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Alexandre Tran Bram Rochwerg Francisco Chacón-Lozsán Health Hematology Hemophilia Hemostasis Hemostasis News Hemostasis Today Karim Soliman Medicine Salmaan Kanji Shannon M. Fernando thrombosis
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