![]() ![]() Thus, hydroxocobalamin acts as a nitric oxide scavenger to limit the significant dysregulated release of nitric oxide seen in severe sepsis. In a significant vasodilatory state such as sepsis, inducible nitric oxide synthase (iNOS) expression, the precursor catalyst of nitric oxide, is increased up to one-thousand fold 8. In addition, the nitrosylcobalamin metabolite itself has anti-inflammatory properties including inhibition of NF-κB and hydrogen sulfide 8. Interestingly, nitrosylcobalamin holds tightly onto nitric oxide, inhibiting nitric oxide’s vasodilatory effects and increasing systemic blood pressure 7. It turns out that this same hydroxyl group can also be displaced by nitric oxide (NO-) in the blood stream to yield nitrosylcobalamin. In treating cyanide poisoning, this hydroxyl group is easily displaced by toxic cyanide (CN-) yielding cyanocobalamin, a benign compound that is renally excreted 7. The prefix ‘hydroxo’ in hydroxocobalamin refers to a hydroxyl group (-OH) that is bounded to a central cobalt. With some understanding of the chemical structure of hydroxocobalamin, the mechanism of hypertension is well understood. In its original approval, the side effect profile included hypertension. The drug was originally marketed with an FDA approval for cyanide toxicity 6. High-dose hydroxocobalamin (vitamin B12) is gaining traction as a potential new approach to reduce the need for conventional vasopressors including catecholamines, vasopressin, and angiotensin II. Vitamin B12, hydroxocobalamin, may be the next in line for evaluation, scrutiny, and debate. With this result, the community has explored alternative therapies to manage septic shock. Most recently, a large trial showed that patients in intensive care who received vitamin C therapy had a higher risk of death or persistent organ dysfunction 5. This fascinating result led to several prospective trials and meta-analyses 3, 4. A controversial retrospective analysis to evaluate the efficacy of vitamin C demonstrated a major reduction in mortality, AKI, and vasopressor duration 2. Vitamin C is thought to have antioxidant effects that attenuate tissue injury mediated by inflammation 1. All rights reserved.In recent years, the critical care community has debated the benefits of vitamin C in septic shock. Hydroxocobalamin/administration & dosage methylene blue/adverse effects methylene blue/therapeutic use postoperative complications/drug therapy vasoplegia/drug therapy.Ĭopyright © 2021 Elsevier Inc. In adult patients undergoing cardiothoracic surgery using CPB with VS, the ability to reduce vasopressor use was similar with hydroxocobalamin compared with methylene blue. There were no significant between-group differences in percentage change in norepinephrine equivalents or vasoactive inotropic score at each timepoint. Baseline demographics, surgical characteristics, and vasoactive medications were similar between groups. After matching, 66 patients in the methylene blue group were included in the analysis. Of the 142 included patients, 120 received methylene blue and 22 received hydroxocobalamin. Patients were included who received either hydroxocobalamin (5,000 mg) or methylene blue (median 1.2 mg/kg) for VS in the operating room during the index surgery or in the intensive care unit up to 24 hours after CPB separation. Eligible patients who received methylene blue were matched 3:1 with patients who received hydroxocobalamin based on sequential organ failure assessment score, preoperative mechanical circulatory support, CPB duration, and use of pre-CPB vasopressors, angiotensin-converting enzyme inhibitors, or beta-blockers.Ī quaternary care academic medical center.Īdult patients who underwent cardiac surgery with CPB from July 2013 to June 2019. The primary endpoints were the percentage change in vasopressor use at 30, 60, and 120 minutes, characterized as both norepinephrine equivalents and vasoactive inotropic score. To compare hydroxocobalamin and methylene blue for the treatment of vasopressor-refractory vasoplegic syndrome (VS) after adult cardiac surgery with cardiopulmonary bypass (CPB).Ī retrospective, propensity-matched, cohort study was performed.
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