Hypotension in Setting of Septic Shock (see Sepsis)
Clinical Efficacy
Case Report of Hydroxocobalamin in Septic Shock (Cureus, 2021) [MEDLINE]
Single Center, Retrospective Case Series of Hydroxocobalamin in Refractory Septic Shock (Crit Care Explor, 2021) [MEDLINE]: n = 26
Hydroxocobalamin Increase in Mean Arterial Pressure at 1, 6, and 24 hrs (+16.3, +14.3, and +16.3 mm Hg, Respectively; p < 0.001)
Increase in Mean Arterial Pressure from Baseline Remained Statistically Significant When Controlling for Age/Sex/Comorbid Conditions
There was No Change in the Norepinephrine Equivalents Patients Required 1 hr Following Hydroxocobalamin, But a Statistically Significant Decrease in Norepinephrine Equivalent was Observed at 6 and 24 hrs (p < 0.001)
Hypotension in Setting of Vasoplegic Syndrome Following Cardiothoracic Surgery
Clinical Efficacy
Retrospective Case Series of Hydroxocobalamin in the Treatment of Cardiac Surgery-Associated Vasoplegia (Can J Anaesth, 2018) [MEDLINE]: n = 33
Patients Received Hydroxocobalamin for Hypotension During or Immediately Following Cardiopulmonary Bypass
Considerable Heterogeneity in Patient Response, Potentially Dependent on Both Patient Preoperative Condition and Non-Standardized Time of Administration
Of the 33 Patients, 9 Patients Had No Response, and the Remainder Either Had an Adequate Initial Response, Prolonged Response, or Had Rebound Hypotension within 2 hrs
Some Nitric Oxide Synthase Inhibitors (NG-Methyl-L-Arginine Hydrochloride, 546C88) Have Been Demonstrated to Resolve Shock in Severe Sepsis (Crit Care Med, 2004) [MEDLINE]
In Contrast, Other Studies of Nitric Oxide Synthase Inhibitors Have Demonstrated that Nitrix Oxide Inhibitors Increase the Mortality Rate in Septic Shock (Crit Care Med, 2004) [MEDLINE]
Inhibition of Hydrogen Sulfide (an Endothelial-Bound Endogenous Vasodilator), Enhancing its Elimination (J Cardiothorac Vasc Anesth, 2019) [MEDLINE]
The use of high-dose hydroxocobalamin for vasoplegic syndrome. Ann Thorac Surg. 2014 May;97(5):1785-6. doi: 10.1016/j.athoracsur.2013.08.050 [MEDLINE]
The Use of Intravenous Hydroxocobalamin as a Rescue in Methylene Blue-resistant Vasoplegic Syndrome in Cardiac Surgery. Ann Card Anaesth. 2017 Oct-Dec; 20(4): 462–464. doi: 10.4103/aca.ACA8817 [MEDLINE]
Hydroxocobalamin for the treatment of cardiac surgery-associated vasoplegia: a case series. Can J Anaesth. 2018 May;65(5):560-568. doi: 10.1007/s12630-017-1029-3 [MEDLINE]
Vasoplegic syndrome following cardiothoracic surgery—review of pathophysiology and update of treatment options. Crit Care. 2020; 24: 36. Published online 2020 Feb 4. doi: 10.1186/s13054-020-2743-8 [MEDLINE]
Hydroxocobalamin in Refractory Septic Shock: A Retrospective Case Series. Crit Care Explor, 2021 Apr; 3(4): e0408. Published online 2021 Apr 26. doi: 10.1097/CCE.0000000000000408 [MEDLINE]
Extended Duration Infusion of Hydroxocobalamin for Vasoplegic Rescue in Septic Shock. Cureus. 2021 Feb; 13(2): e13388 [MEDLINE]
Pharmacology
Spectroscopic studies of nitric oxide (NO) interactions with cobalamins: reaction of NO with superoxocobalamin(III) likely accounts for cobalamin reversal of the biological effects of NO. J Pharmacol Exp Ther. 1998 May;285(2):665-71 [MEDLINE]
Administration of the nitric oxide synthase inhibitor NG-methyl-L-arginine hydrochloride (546C88) by intravenous infusion for up to 72 hours can promote the resolution of shock in patients with severe sepsis: results of a randomized, double-blind, placebo-controlled multicenter study (study no. 144-002). Crit Care Med. 2004 Jan;32(1):1-12. doi: 10.1097/01.CCM.0000105118.66983.19 [MEDLINE]
Multiple-center, randomized, placebo-controlled, double-blind study of the nitric oxide synthase inhibitor 546C88: effect on survival in patients with septic shock. Crit Care Med. 2004 Jan;32(1):21-30. doi: 10.1097/01.CCM.0000105581.01815.C6 [MEDLINE]
Inhibition of nitric oxide synthase by cobalamins and cobinamides. Free Radic Biol Med. 2009 Jun 15;46(12):1626-32. doi: 10.1016/j.freeradbiomed.2009.03.017 [MEDLINE]
Hydroxocobalamin for the Treatment of Vasoplegia: A Review of Current Literature and Considerations for Use. J Cardiothorac Vasc Anesth. 2019 Apr;33(4):894-901. doi: 10.1053/j.jvca.2018.08.017 [MEDLINE]
Adverse Effects
Discoloration of skin and urine after treatment with hydroxocobalamin for cyanide poisoning. CMAJ. 2009 Jan 20; 180(2): 251 [MEDLINE]
Risk of oxalate nephropathy with the use of cyanide antidote hydroxocobalamin in critically ill burn patients. Intensive Care Med. 2016 Jun;42(6):1080-1. doi: 10.1007/s00134-016-4252-4 [MEDLINE]
