Local Cutaneous Necrosis Secondary to a Prolonged Peripheral Infusion of Methylene Blue in Vasodilatory Shock

Objective:To report a case of methylene blue extravasation and subsequent tissue necrosis in a patient with refractory septic shock.Case Summary:A 47-year-old female presented with febrile neutropenia secondary to chemotherapy. The patient quickly decompensated to refractory septic shock in the critical care unit despite implementation of early goal-directed therapy as well as intravenous norepinephrine and vasopressin to stabilize her hemodynamic status. She received a 16-hour infusion of 1% methylene blue 0.25 mg·kg−1 ·h−1, titrated up to 0.5 mg ·kg−1 ·h−1, via a peripheral intravenous catheter. Ten hours after the start ot the methylene blue infusion, she experienced a local extravasation injury, which led to distal digital necrosis. While her hemodynamic status improved dramatically, allowing discharge from the intensive care unit and eventually to home, the extravasation site became necrotic and required debridement and skin graft.Discussion:Methylene blue is a vasoactive chemical that has been shown...