Page 10 - World Journal of Laparoscopic Surgery

Rebecca Bagadia, Vishwa Kanabar
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Preoperative patient analyses are ruling out glucose- dye causing methemoglobinemia. Bilgin et al also pre-
6-phosphate dehydrogenase (G6PD) deficiency, history of sented a case of methemoglobinemia after methylene blue
allergy to drugs and dyes, and history of chronic pelvic instillation, but his patient had G6PD deficiency. Herath
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infection. Drug analysis like the right amount of dilution; et al stated that bluish discoloration can occur without
the right amount to be installed; identification of signs methemoglobinemia as their patient developed bluish
and symptoms on table or during perioperative period; discoloration and cyanosis immediately after injection of
the immediate treatment management protocol like epi- 20 mL of the dye intracervically for diagnostic laparoscopy;
nephrine, steroids, histamine 1 and 2 blocking agents, this could be an anaphylactic reaction to the dye or they
and oxygen administration; postoperative cutaneous might have used a concentrated version instead of 1%.
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test; and systematic allergiological investigation of all Ash-Bernal et al did a retrospective study on 138 cases
the drugs and substances given during the perioperative where they discussed about the acquired cause of met-
period is important. hemoglobinemia. The most common drug causing it is
dapsone.
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DISCUSSION Robert and Barbieri recommend using 10 mg of
methylene blue in 150 mL of NS to reduce the symptoms
Normally, methemoglobin levels are <1% when measured of anaphylaxis.
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by co-oximetry test. Cyanosis is the classic symptom of Dewachter et al observed severe immunoglobulin
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methemoglobinemia; this occurs when methemoglobin E-mediated hypersensitivity reaction to 1% methylene
>1%. Other signs and symptoms include mental status blue; cutaneous test and biological assessment positivity
changes, shortness of breath, headache, fatigue, dizziness, confirmed anaphylactic reaction to methylene blue, so
and loss of consciousness. Severe methemoglobinemia investigation is necessary. In Millo et al’s case after diag-
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is when methemoglobin >50% where patients have dys- nostic laparoscopy for infertility, patient was shifted to
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rhythmias, seizures, coma, and death. In patients with the recovery room; about 15 minutes later, she developed
conditions like anemia, heart and lung disease, G6PD restlessness, cyanosis, and was not maintaining oxygen
deficiency, and sepsis, methylene blue can induce met- saturation. Despite efforts of resuscitation, she died. On
hemoglobinemia even at normal levels. 8 postmortem findings, the lungs were edematous, con-
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Veerendrakumar et al had injected 20 to 30 mL of 1% gested, blue stained, with features of pulmonary edema.
methylene blue, and 5 hours later, the patient developed Dhanpal and Joseph injected 30 mL of 1% of methylene
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tachypnea, hypotension, bilateral basal crepitations, and blue intracervically; 15 minutes later, patient turned blue
bluish-colored urine; patient was transferred to the inten- with central and peripheral cyanosis. Oxygen saturation
sive care unit and treated with oxygen, inotropes, and dropped spontaneously, and spectrophotometric analysis
furosemide. According to the studies, one should always showed methemoglobinemia. Rzymski et al discussed
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keep in mind the dangerous effect of methylene blue, alter- a case of anaphylactic reaction to methylene blue after
natively diluted povidone iodine can be used. This patient chromopertubation.
had developed methemoglobinemia 26.4% (according to
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spectrometric analysis). In Trikha et al’s case, the patient CONCLUSION
weighed 53 kg; 20 mL of 1% methylene blue was injected.
After 2 minutes, the oxygen saturation declined, and after It is important to publish clinical research article on the
5 minutes patient developed crepitations and cyanosis; dangerous adverse outcome from techniques commonly
at 200 mL of fluid patient developed very rare features. used in clinical practice. All these cases highlighted the
The safe limit of the dye is 7 mg/kg. Anaphylactoid reac- fact that methylene is highly potential in causing compli-
tion occurred due to the dye causing intrapulmonary cations that are life-threatening even when not admin-
vascular vasospasm; a generalized vasoconstriction and istered nonsystematically. This research article confirms
some amount of anemic hypoxia could have caused this. that we need continuous and vigilant monitoring in the
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According to Nolan when the patient was injected with preoperative, intraoperative, and postoperative period;
methylene blue dye intracervically, she developed inflam- none of the complaints should be taken for granted even
matory peritonitis after approximately 24 hours, where she if it is as simple as a cough. Anesthetists and surgeons
complained of abdominal distention and pain; exploratory should know the immediate treatment protocol and
laparotomy was done revealing peritoneal ascites and should not be careless in using methylene blue dye in
sterile inflammatory exudates. This pt was treated with any amount or in any concentration.
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corticosteroids. According to Mhaskar and Mhaskar, ACKNOWLEDGMENT
methylene blue is a treatment for methemoglobinemia, but
his patient had tuberculosis, i.e., chronic pelvic inflamma- Author would like to thank her husband Dr Pravin
tory disease, which could be the cause of extravasation of Bagadia for supporting her in doing this research article.
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