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Washington University Experience | MISCELLANEOUS | Methylene Blue Treatment | 2A0 Case 2 History
Case 2 History ---- The patient was a 67-year-old male with a history of coronary artery disease (status post coronary artery bypass graft), congestive heart failure (CHF), hypertension, atrial fibrillation (AF) (status post ablation, on Tikosyn and warfarin), atrial flutter, and recent pathologic fracture of the proximal right humerus. He presented to the BJH ED on October 2 with hypotension and fluid overload resulting in pleural effusions and diffuse anasarca due to non-compliance with furosemide. He received norepinephrine and was admitted to the ICU for CHF exacerbation, kidney injury, warfarin supratherapeutic (INR 5.5) and undifferentiated shock. Warfarin was held and heparin was started once his INR improved. He was diuresed and started on steroids and broad-spectrum antibiotics for shock. On 10/5, AF with rapid ventricular rate (AFRVR) was noted and a cardiology consult was placed. He was started on amiodarone without improvement. He was placed on BiPAP for hypoxemia with worsening effusions despite furosemide. He was found to be supratherapeutic on heparin (PTT >150 s) and developed epistaxis. That night, he decompensated with increasing pressor requirements and worsening epistaxis. Cardioversion was attempted but was unsuccessful and he was intubated. On 10/6, a bronchial alveolar lavage showed bloody return. He developed a fever. He began continuous venovenous hemodiafiltration. A trial of methylene blue was administered on 10/7 with some improvement in pressures and subsequently a drip was started. On 10/9, he was no longer on methylene blue, voriconazole, or angiotensin II, though still in AF but with some improvement in heart rate and lactate. He continued to decline with hypotension and a persistent leukocytosis (to 30K/ccm) which had developed. Methylene blue loading was repeated given improvement seen previously. Overnight he was transitioned to comfort care given his poor prognosis with worsening status despite intervention. He became unresponsive and died on 10/15.
