Introduction
Vasoplegic syndrome (VS) is an entity characterized by uncontrolled vasodilation and shock despite administration of large doses of vasopressors (1,2). Since description in 1997, diverse drugs have been undergoing clinical trials to find alternatives when everything else has failed (1). Recent reports and studies using methylene blue (MB) are promising. MB has even been nicknamed “The Magic Bullet for Vasoplegia” in an “Anesthesia & Analgesia” review article of 2016 (2).

Case Report
A 41-year old man was diagnosed with an extremely rare retroperitoneal dopamine-only-producing ganglioneuroma and scheduled for surgery under general balanced anesthesia. Alpha and beta blockade was achieved preoperatively using phenoxybenzamine and propranolol. Surgery was uneventful until 20 minutes after vein ligation. Monitored with pulse pressure contour analysis of hemodynamic parameters (ProAQT®), marked hypotension due to a profound decrease in indexed vascular resistances (ISR) was observed – 400 dyn.s/cm5.m2 (1700 – 2400) –. There was no response to dopamine (10 mcg/Kg/min) and noradrenaline (60 mcg/min). MB was administrated and resulted in an immediate normalization of ISR and blood pressure, as well as withdrawal of all vasopressor support 10 minutes after MB bolus.

Discussion
Reports showing MB is a successful resource when vasopressors fail are being increasingly published (1,2). There is only one similar case of MB administration after alpha blockade (3). MB inhibits nitrous oxide (NO) synthesis and activity, rendering vessels unresponsive to NO and increasing ISR (1,2). There is still debate about when, how, and how much MB should be given, and if outcomes improve. But MB is undoubtfully emerging as a valuable resource in shock when no alternatives are found (2).

References
(1)	Evora, P. Twenty years of vasoplegic syndrome treatment in heart surgery. Methylene blue revised. Braz J of Cardiovasc Surg. 2015; 30(1): 84-92.
(2)	Hosseinian, L. Methylene Blue: Magic Bullet for Vasoplegia? Anesthesia & Analgesia. 2016; 122(1): 194-201.
(3)	Nasr, A. Use of methylene blue in pheochromocytoma resection: case report. Pediatric Anesthesia. 2009; 19: 396–401.

Learning Points
•	VS is an entity characterized by profound hypotension despite intravenous administration of large doses of vasopressors.
•	MB increases blood pressure and can be a suitable drug when everything else have failed, possibly improving outcomes.

09 / Methylene blue for vasopressor amine non-responsive vasoplegic syndrome after dopamine-producing ganglioneuroma resection: a case report