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ALL YOU EVER (NEVER?) WANTED TO KNOW ABOUT INDIGO CARMINE & METHYLENE BLUE. YEE L. KWAN, RN, CCRN DUNAP, CLASS OF 2013 APRIL 9 TH, 2012
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ALL ABOUT THE BLUE STUFF… By the end of this presentation you should be able to……. 1.List the indications for use of indigo carmine (IC) and methylene blue (MB) 1.Identify risks associated with the use of these drugs 2.Discuss some off-label uses for these drugs
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INDIGO CARMINE Dye Concentrated by kidneys, excreted in urine Diagnosis/visualization of urinary fistulae/ureteral orifices during cysto Endoscopic examination of gastric CA Adjustments to catheters for chemo in hepatic & oralmaxillo-facial tumors. Give undiluted IVP or intramuscularly 40-80mg (5-10ml) – 0.8% sol’n Generally considered pharmacologically inert
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CASE STUDIES Hypertensive crisis Anaphylactoid reaction Bradycardia Cardiac arrest
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METHYLENE BLUE Dye 75% of dose excreted renally Diagnosis/visualization of urinary fistulae/ureteral orifices during cysto 1-2mg/kg IVP over several minutes Do NOT give SQ or IM Many interesting uses
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CASE STUDIES Encephalopathy Serotonin toxicity Vasoplegic syndrome Alternative to lidocaine Cure for Alzheimers?
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IN SUMMARY….. 1.More studies needed 2.There is no such thing as a benign drug 3.A wise man once said…”Titrate, titrate, titrate.”
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QUESTIONS FOR THOUGHT….. Will you think about this the next time you go to give either of these drugs? Would you give MB as a treatment for vasoplegic syndrome? How about MB for pain of propofol injection?
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References: Flewellen, E. H. (1980). Hazards of intravenous indigo carmine, fluorescein, and methylene blue. Texas medicine, 76(10), 49-51. Gillman, P. K. (2011). CNS toxicity involving methylene blue: the exemplar for understanding and predicting drug interactions that precipitate serotonin toxicity. [Review]. Journal of psychopharmacology, 25(3), 429-436. doi: 10.1177/0269881109359098 Gousse, A. E., Safir, M. H., Madjar, S., Ziadlourad, F., & Raz, S. (2000). Life-threatening anaphylactoid reaction associated with indigo carmine intravenous injection. [Case Reports]. Urology, 56(3), 508. Jeffords, D. L., Lange, P. H., & DeWolf, W. C. (1977). Severe hypertensive reaction to indigo carmine. [Case Reports]. Urology, 9(2), 180-181. McDonagh, D. L., McDaniel, M. R., & Monk, T. G. (2007). The effect of intravenous indigo carmine on near-infrared cerebral oximetry. [Case Reports Research Support, Non-U.S. Gov't]. Anesthesia and analgesia, 105(3), 704-706. doi: 10.1213/01.ane.0000271917.20429.50 Naitoh, J., & Fox, B. M. (1994). Severe hypotension, bronchospasm, and urticaria from intravenous indigo carmine. [Case Reports]. Urology, 44(2), 271-272. Parlow, J. L., & van Vlymen, J. M. (2008). [The methylene blues: anticipating adverse reactions to non-anesthetic drugs]. [Comment Editorial]. Canadian journal of anaesthesia = Journal canadien d'anesthesie, 55(1), 1-5. doi: 10.1007/BF03017590 Salman, A. E., Salman, M. A., Saricaoglu, F., Akinci, S. B., & Aypar, U. (2011). Pain on injection of propofol: a comparison of methylene blue and lidocaine. [Comparative Study Randomized Controlled Trial]. Journal of clinical anesthesia, 23(4), 270-274. doi: 10.1016/j.jclinane.2010.09.008
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Satoh, K., Sakamoto, N., Shinohe, Y., Satoh, M., & Joh, S. (2001). Indigo carmine-induced bradycardia in a patient during general anesthesia. [Case Reports]. Anesthesia and analgesia, 92(1), 276-277. Shanmugam, G. (2005). Vasoplegic syndrome--the role of methylene blue. [Review]. European journal of cardio- thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 28(5), 705-710. doi: 10.1016/j.ejcts.2005.07.011 Stanford, S. C., Stanford, B. J., & Gillman, P. K. (2010). Risk of severe serotonin toxicity following co-administration of methylene blue and serotonin reuptake inhibitors: an update on a case report of post-operative delirium. [Case Reports Review]. Journal of psychopharmacology, 24(10), 1433-1438. doi: 10.1177/0269881109105450 Sweet, G., & Standiford, S. B. (2007). Methylene-blue-associated encephalopathy. [Research Support, Non-U.S. Gov’t Review]. Journal of the American College of Surgeons, 204(3), 454-458. doi: 10.1016/j.jamcollsurg.2006.12.030
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