Methemoglobinemia from Intravenous Nitroglycerin: A Word of Caution

doi:10.1016/S0003-4975(10)60627-3

The Annals of Thoracic Surgery

Volume 43, Issue 3, March 1987, Pages 332-334

https://doi.org/10.1016/S0003-4975(10)60627-3 Get rights and content

Abstract

The dose of intravenously administered nitroglycerin (IV NTG) used to control ischemic chest pain usually is limited by hypotension from decreased preload. Herein we describe 2 patients who tolerated IV NTG without hemodynamic compromise but in whom severe impairment of blood oxygen content developed from methemoglobinemia noted during coronary bypass surgery. Methemoglobinemia must be suspected if chocolate-brown blood is encountered despite a normal arterial oxygen tension and calculated oxygen saturation. Before a methemoglobin level is available, the extent of hypoxemia can be determined by an oximetric oxygen saturation and therapy begun with intravenous administration of methylene blue. These case reports focus attention on the potential deleterious effects of undetected hypoxemia from methemoglobinemia in patients being stabilized with high-dose IV NTG for urgent cardiac surgery.

References (19)

NS Hill et al.
Intravenous nitroglycerin: a review of pharmacology, indications, therapeutic effects, and complications
Chest
(1981)
JA Kaplan et al.
Vasodilator therapy during coronary artery surgery: comparison of nitroglycerin and nicroprusside
J Thorac Cardiovasc Surg
(1979)
SE Fremes et al.
A comparison of nitroglycerin and nitroprusside: II. The effects of volume loading
Ann Thorac Surg
(1985)
SE Fremes et al.
A comparison of nitroglycerin and nitroprusside: I. Treatment of postoperative hypertension
Ann Thorac Surg
(1985)
F Robicsek
Acute methemoglobinemia during cardiopulmonary bypass by intravenous nitroglycerin infusion
J Thorac Cardiovasc Surg
(1985)
SA Saxon et al.
Effects of continuous infusion of intravenous nitroglycerin infusion on methemoglobin levels
Am J Cardiol
(1985)
B Husum et al.
Methaemoglobin formation after nitroglycerin infusion
Br J Anaesth
(1982)
KJ Kaplan et al.
Association of methemoglobinemia and intravenous nitroglycerin administration
Am J Cardiol
(1985)
E Beutler
Methemoglobinemia and sulfhemoglobinemia

There are more references available in the full text version of this article.

Cited by (17)

Preclusion of methemoglobinemia caused by nitrate drugs in diabetics and nondiabetics: Possible role of Vitamin C
2022, Blood Cells, Molecules, and Diseases
Citation Excerpt :
Nitrites cause the oxidation of hemoglobin to methemoglobin [3]. Several reports have been published showing that therapeutic doses of organic nitrates have caused significant methemoglobinemia [4–7]. Methemoglobin formation is an indicator for oxidative stress in diabetic patients [8].
The drugs containing nitrates like isosorbide dinitrate, isosorbide mononitrate and glyceryl trinitrate, etc., trigger the oxidation of hemoglobin which is manifested in the pathological disorder named methemoglobinemia. It was considered interesting to investigate the preventive roles of vitamin C towards the toxic effects of nitrate containing drugs used for the treatment of angina. The aim is to find whether these drugs need to be administered with special care to diabetic patients who are more prone to develop methemoglobinemia. Vitamin C (500 mg/day) was administered orally to reduce the methemoglobin (metHb) level in both the diabetic and nondiabetic patients consuming nitrate containing drugs regularly, keeping diabetic and nondiabetic patients not on nitrate drugs as control. Concentration of metHb and hemoglobin A (HbA) was estimated spectrophotometrically assuming the molar extinction coefficient values of metHb as 3.78 mM^‐⁻¹ cm^‐⁻¹ at 630 nm and HbA as 125,000 M ^‐⁻¹ cm ^‐⁻¹ at 415 nm. MetHb level was found to be lower after the treatment with vitamin C for 30 consecutive days than that before the trial with statistically significant two tailed p value. Additionally, fasting insulin level was also found to decrease after 4 weeks of consumption of vitamin C with moderate lowering of fasting serum glucose level as well, indicating a higher insulin sensitivity for the treated patients.
Late diagnosis of congenital methemoglobinemia in an elderly patient during cardiac surgery
2014, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Antioxidant drugs, such as ascorbic acid or riboflavin (vitamin B2), also have been proposed for the long-term treatment of cyanosis.3 Several cases of management of methemoglobinemia during general anesthesia have been described in medical literature, especially with respect to cardiac surgery.4,7,8 However, a lot of them concern toxic-induced methemoglobinemia or supposed and not proven of congenital etiology.
Toxic Methemoglobinemia Caused by Topical Anesthetic Given Before Transesophageal Echocardiography
1991, Journal of the American Society of Echocardiography
Transesophageal echocardiography was performed on a patient with critical aortic stenosis and severe three-vessel coronary artery disease. Immediately after the procedure the patient experienced marked cyanosis (oxygen saturation of 53%) secondary to methemoglobinemia (methemoglobin saturation of 45%). Toxic methemoglobinemia was thought to be caused by topical anesthetic. He responded dramatically to treatment with intravenous methylene blue. Toxic methemoglobinemia should be suspected in unexplained cyanosis occurring after transesophageal echocardiography and other endoscopic procedures during which potentially causative agents have been used.
Methemoglobinemia secondary to aniline exposure
1990, Annals of Emergency Medicine
Methemoglobinemia masquerading as pulmonary hypertension
2004, Interactive Cardiovascular and Thoracic Surgery
Tailoring the management of hypertension to comorbidities
2021, Current Opinion in Cardiology

View all citing articles on Scopus

View full text

Methemoglobinemia from Intravenous Nitroglycerin: A Word of Caution

Abstract

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Cardiol

Br J Anaesth

Am J Cardiol

Methemoglobinemia and sulfhemoglobinemia