Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942004000600010
Brazilian Journal of Anesthesiology
Clinical Information

Uso do azul de metileno no tratamento de choque anafilático durante anestesia: relato de caso

Methylene blue to treat anaphylaxis during anesthesia: case report

Renato Mestriner Stocche; Luís Vicente Garcia; Marlene Paulino dos Reis; Jyrson Guilherme Klamt; Paulo Roberto B. Évora

http://dx.doi.org/10.1590/S0034-70942004000600010 Braz J Anesthesiol, vol.54, n6, p.809-814, 2004
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Resumo

JUSTIFICATIVA E OBJETIVOS: No período peri-operatório, o risco de anafilaxia deve sempre ser considerado. A incidência de reações alérgicas em anestesia é controversa, variando entre 1/3000 a 1/20.000, com mortalidade entre 3% e 9 %. Neste caso, relata-se o uso do azul de metileno como coadjuvante ao tratamento do choque anafilático refratário à terapêutica tradicional. RELATO DO CASO: Paciente do sexo masculino, 53 anos, submetido a herniorrafia inguinal sob raquianestesia. No final do procedimento, ao receber dipirona (1,5 g), por via venosa, o paciente imediatamente apresentou broncoespasmo, cianose, diminuição da SpO2 e da PAS, culminando com parada cardiorrespiratória. Foi iniciada reanimação cardiorrespiratória com massagem cardíaca externa, seguida de IOT e injeção de adrenalina (1 mg), atropina (1 mg), restabelecendo-se FC de 150 bpm, porém sem pulso palpável. Administrou-se mais 1 mg de adrenalina além de 1 g de hidrocortisona, com restabelecimento de pulso central (8 minutos). Apesar de receber dopamina (20 µg.kg-1.min-1), o paciente manteve-se hipotenso (60 mmHg) até 80 minutos. Administraram-se 100 mg de azul de metileno por via venosa, quando houve aumento da PAS para 85 e 105 mmHg, após a segunda dose. Seguiu-se da diminuição da dose de dopamina de 20 para 10, 7, 5 e, finalmente, 2 µg.kg-1.min-1. CONCLUSÕES: A anafilaxia tem como principal mediador a liberação de histamina, que induz a produção de óxido nítrico (NO), com conseqüente aumento da guanilato ciclase que promove vasodilatação arteriolar por aumento do GMP cíclico. O azul de metileno pode ser útil nestas situações, pois inibe a guanilato ciclase e conseqüentemente a vasodilatação, o que resulta em melhora hemodinâmica.

Palavras-chave

ANALGÉSICOS, COMPLICAÇÕES, DROGAS

Abstract

BACKGROUND AND OBJECTIVES: The risk of perioperative anaphylaxis should always be considered. The incidence of anesthetic allergic reactions is controversial, varying from 1/3,000 to 1/20,000, with mortality range between 3 and 9%. This report describes the use of methylene blue as coadjuvant drug to treat anaphylaxis refractory to conventional therapy. CASE REPORT: A 53-year-old male patient was submitted to inguinal hernia correction under spinal anesthesia. After receiving 1.5 g intravenous dipirone at surgery completion, he immediately developed bronchospasm, cyanosis, decreased SpO2 and SBP, culminating with cardiac arrest. Resuscitation was started with external cardiac massage followed by tracheal intubation, as well as 1 mg epinephrine and 1 mg atropine injections. Heart rate returned (150 bpm) with no palpable pulse though. Additional 1 mg epinephrine and 1 g hydrocortisone were administered with central pulse recovery (8 minutes). Although receiving dopamine (20 µg.kg-1.min-1), patient remained hypotensive (60 mmHg) until 80 minutes. Intravenous 100 mg methylene blue was then administered with increased SBP to 85 and 105 mmHg after the second dose. Dopamine dose was tapered from 10 to 7, 5 and finally 2 µg.kg-1.min-1. CONCLUSIONS: Histamine is the major anaphylaxis mediator. Inducing nitric oxide (NO) production, it consequently increases guanylate cyclase, which promotes arteriolar vasodilation by increasing cyclic GMP. Methylene blue may be helpful in such situations because it inhibits guanylate cyclase and consequently vasodilation, resulting in hemodynamic improvement.

Keywords

ANALGESICS, COMPLICATIONS, DRUGS

References

Alam M, Anrep GV, Barsoum GS. Liberation of histamine from the skeletal muscle by curare. J Physiol. 1939;95:148-158.

Drug induced anaphylaxis. J Am Med Assoc. 1973;224:613-615.

Fisher MM, Baldo BA. Anaphylactoid reactions during anaesthesia. Clin Anaesth. 1984;3:677-692.

McKinnon RP, Wildsmith JA. Histaminoid reactions in anaesthesia. Br J Anaesth. 1995;74:217-228.

Babe KS, Serafin WE. Histamine, Bradykinin, and their Antagonist. Pharmacological Basis of Therapeutics. 1996.

Mitsuhata H, Shimizu R, Yokoyama MM. Role o nitric oxide in anaphylactic shock. J Clin Immunol. 1995;15:277-283.

Osada S, Ichiki H, Oku H. Participation of nitric oxide in mouse anaphylactic hypotension. Eur J Pharmacol. 1994;252:347-350.

Mitsuhata H, Saitoh J, Takeuchi H. Production of nitric oxide in anaphylaxis in rabbits. Shock. 1994;2:381-384.

Rapoport RM, Murad F. Agonist-induced-endothelium dependent relaxation in rat thoracic aorta may be mediated through cGMP. Cir Res. 1983;52:352-357.

Fisher MM, Baldo BA. The incidence and clinical features of anaphylactic reactions during anesthesia in Australia. Ann Franc Anesth Reanim. 1993;12:97-104.

Fisher MM. Clinical observations on the pathophysiology and treatment of anaphylactic cardiovascular collapse. Anaesth Intensive Care. 1986;14:17-21.

Laxenaire MC, Moneret-Vautrin DA, Boileau S. Adverse reactions to intravenous agents in anaesthesia in France. Klin Wochenschr. 1982;60:1006-1009.

Fisher MM, Baldo BA. Acute anaphylactic reactions. Med J Aust. 1988;149:34-38.

Abend Y, Ashkenazy Y, Witzling V. Nitric oxide: a mediator in anaphylactic shock in guinea-pigs. J Basic Clin Physiol Pharmacol. 1996;7:57-69.

Mitsuhata H, Takeuchi H, Saitoh J. An inhibitor of nitric oxide, N omega-nitro-L-arginine-methyl ester, attenuates hypotension but does not improve cardiac depression in anaphylaxix in dogs. Shock. 1995;3:447-453.

Mitsuhata H, Saitoh J, Hasome N. Nitric oxide synthase inhibition is detrimental to cardiac function and promotes bronchospasm in anaphylaxis in rabbits. Shock. 1995;4:143-148.

Burrows GE. Methylene blue: effects and disposition in sheep. J Vet Pharmacol Ther. 1984;7:225-231.

Marczin N, Tekeres M, Salzman AL. Methylene blue infusion in septic shock. Crit Care Med. 1995;23:1936-1938.

Preiser JC, Lejeune P, Roman A. Methylene blue administration in septic shock: a clinical trial. Crit Care Med. 1995;23:259-264.

Zhang H, Rogiers P, Preiser JC. Effects of methylene blue on oxygen availability and regional blood flow during endotoxic shock. Crit Care Med. 1995;23:1711-1721.

Andrade JCS, Batista Filho ML, Evora PRB. Utilização do azul de metileno no tratamento da síndrome vasoplégica após cirurgia cardíaca. Rev Bras Cirurg Cardiovasc. 1996;11:107-114.

Dagenais F, Mathieu P. Rescue therapy with methylene blue in systemic inflammatory response syndrome after cardiac surgery. Can J Cardiol. 2003;19:167-169.

Daemen-Gubbels CR, Groeneveld PH, Groeneveld AB. Methylene blue increases myocardial function in septic shock. Crit Care Med. 1995;23:1363-1370.

Evora PR, Roselino CH, Schiavetto PM. Methylene blue in anaphylatic shock. Ann Emerg Med. 1997;30:240.

Evora PRB, Roselino CHCD, Schiavetto PM. Utilização do azul de metileno no tratamento do choque anafilático. Uma proposiçao clínica e apresentaçao de três casos. Rev Bras Terap Intens. 1997;9:126-131.

Evora PR, Oliveira Neto AM, Duarte NM. Methylene blue as treatment for contrast medium-induced anaphylaxis. J Postgrad Med. 2002;48:327.

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