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YEE L. KWAN, RN, CCRN
DUNAP, CLASS OF 2013
APRIL 9 TH , 2012

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

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

CASE STUDIES
• Hypertensive crisis
• Anaphylactoid reaction
• Bradycardia
• Cardiac arrest

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

CASE STUDIES
• Encephalopathy
• Serotonin toxicity
• Vasoplegic syndrome
• Alternative to lidocaine
• Cure for Alzheimers?

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.”

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?

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

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 cardiothoracic 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