Methylene Blue for Refractory Shock Due to Acute Pancreatitis and Cholangitis

Methylene blue is emerging as a promising adjunctive therapy for refractory septic shock, enabling reduced vasopressor use and fewer intensive care and hospital days. We present the case of a 78-year-old woman with acute pancreatitis and cholangitis who was initially treated with antibiotics, IV fluids, and endoscopic retrograde cholangiopancreatography but had persistent shock with vasopressor requirements. She was then treated with methylene as a 1 mg/kg bolus, followed by another 1 mg/kg infusion over six hours, to reduce overall pressor requirements. She improved significantly within hours of receiving methylene blue, as evidenced by the weaning of vasopressor support. Upon receiving the culture results, antibiotics could be de-escalated. She continued to improve and was soon able to transfer out of the intensive care unit and was ultimately discharged. This case highlights the potential promise of early methylene blue administration in patients with refractory septic shock. It emphasizes that initiation of methylene blue may occur before confirmatory culture data is available.