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Methylene Blue for Refractory Shock in Children: A Systematic Review and Survey Practice Analysis
Andrea V Otero Luna1, Rachel Johnson1, Melissa Funaro2
1Department of Pediatrics, Yale University, New Haven, CT.
Insights
Methylene blue shows promise for treating pediatric refractory shock, appearing safe and potentially beneficial. However, physician familiarity and usage patterns are divided, highlighting a need for more research.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacology
- Clinical Research
Background:
- Refractory shock in children carries high morbidity and mortality.
- The use of methylene blue for pediatric refractory shock is not well-documented.
- Understanding current physician practices is crucial.
Purpose of the Study:
- To systematically review literature on methylene blue for pediatric refractory shock.
- To define current physician practice patterns regarding methylene blue use in pediatric shock.
Main Methods:
- Systematic literature search (MEDLINE, Embase, PubMed, Web of Science, Cochrane) up to 2019.
- Qualitative analysis of included studies (24 studies identified).
- Electronic survey distributed to U.S. pediatric critical care physicians to assess knowledge and experience.
Main Results:
- Methylene blue was found to be generally safe and increased mean arterial blood pressure in pediatric patients with refractory shock.
- A significant lack of high-quality studies with low patient numbers was identified.
- Physician usage patterns were divided: 40% used methylene blue, 43% never considered it, citing unfamiliarity, dosing concerns, and lack of evidence.
Conclusions:
- Methylene blue appears safe and potentially beneficial for pediatric refractory shock.
- There is a notable disparity in physician familiarity and practice patterns regarding methylene blue.
- Further rigorous studies are warranted to establish the safety and efficacy of methylene blue in pediatric shock treatment.
Objectives:
Shock refractory to fluid and catecholamine therapy has significant morbidity and mortality in children. The use of methylene blue to treat refractory shock in children is not well described. We aim to collect and summarize the literature and define physicians' practice patterns regarding the use of methylene blue to treat shock in children.
Design:
We conducted a systematic search of MEDLINE, Embase, PubMed, Web of Science, Cochrane for studies involving the use of methylene blue for catecholamine-refractory shock from database inception to 2019. Collected studies were analyzed qualitatively. To describe practice patterns of methylene blue use, we electronically distributed a survey to U.S.-based pediatric critical care physicians. We assessed physician knowledge and experience with methylene blue. Survey responses were quantitatively and qualitatively evaluated.
Setting:
Pediatric critical and cardiac care units.
Patients Or Subjects:
Patients less than or equal to 25 years old with refractory shock treated with methylene blue.
Interventions:
None.
Measurements And Main Results:
One-thousand two-hundred ninety-three abstracts met search criteria, 139 articles underwent full-text review, and 24 studies were included. Studies investigated refractory shock induced by a variety of etiologies and found that methylene blue was generally safe and increased mean arterial blood pressure. There is overall lack of studies, low number of study patients, and low quality of studies identified. Our survey had a 22.5% response rate, representing 125 institutions. Similar proportions of physicians reported using (40%) or never even considering (43%) methylene blue for shock. The most common reasons for not using methylene blue were unfamiliarity with this drug, its proper dosing, and lack of evidentiary support.
Conclusions:
Methylene blue appears safe and may benefit children with refractory shock. There is a stark divide in familiarity and practice patterns regarding its use among physicians. Studies to formally assess safety and efficacy of methylene blue in treating pediatric shock are warranted.
