Use of Methylene Blue in the Management of Refractory Shock in Pediatric Intensive Care Units: A Nationwide Assessment of Clinical Practice in Türkiye
A 2026 nationwide survey of Turkish pediatric intensive care physicians reveals that while methylene blue is commonly used for catecholamine-resistant septic shock, significant variations exist in dosing, monitoring, and safety practices, underscoring the urgent need for standardized protocols and further research.
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When a child's body goes into shock, it is a race against time to restore blood flow to vital organs. In the most severe cases, known as refractory shock, the blood vessels become dangerously relaxed and fail to squeeze tight enough to push blood where it needs to go, even when doctors pump powerful drugs into the child's veins to force them to constrict. This state, often called vasoplegia, leaves the heart working overtime while the body's tissues starve for oxygen. For decades, the medical toolkit for this crisis has been limited to these adrenaline-like drugs and fluids. However, when these standard treatments fail, physicians have begun turning to an old, blue dye called methylene blue. Originally used to treat malaria and as a stain in laboratories, this substance has a unique ability to block the chemical signals that cause blood vessels to relax, effectively acting as a switch to tighten the vessels and raise blood pressure when other methods have stopped working.
The question of whether to use this blue dye in children, and exactly how to do it safely, has remained a matter of debate because large, definitive studies are scarce. To understand how doctors in Turkey are currently handling this dilemma, a team of researchers from Selçuk University conducted a nationwide survey. They reached out to the country's pediatric intensive care specialists, fellows, and faculty members to ask a simple but critical question: Are you using methylene blue for children in shock, and if so, how are you doing it? The goal was not to test the drug on patients, but to map the real-world landscape of medical practice, revealing what doctors are actually doing in the heat of a crisis when standard care fails.
The researchers sent their questionnaire to doctors across all seven geographical regions of Turkey, gathering responses from seventy unique physicians working in pediatric intensive care units. The results showed that the use of this blue rescue therapy has become quite common in the country. Nearly three-quarters of the doctors surveyed, specifically 72.9 percent, reported that they had used methylene blue at least once to treat a child with shock that did not respond to standard drugs. This high rate of adoption was consistent across different types of hospitals and experience levels, suggesting that the practice has moved beyond experimental trials and into routine emergency care for many specialists. The primary reason for its use was almost always the same: children whose septic shock had become resistant to catecholamines, the powerful drugs usually given to raise blood pressure.
While the decision to use the drug was widespread, the way doctors administered it was far from uniform. There was no single, agreed-upon recipe for how much to give or how long to keep it running. The most common approach, used by about 71 percent of those who used the drug, was to give a quick shot of the medicine followed by a continuous drip. However, the specific amounts varied significantly. Among those who gave a starting dose, most chose one milligram per kilogram of the child's body weight, but the rate at which they continued the drip differed, with nearly half of the doctors preferring one milligram per kilogram per hour. This lack of a standard protocol meant that one child might receive a different treatment regimen than another, even if they were in the same hospital.
The timing of the treatment also showed considerable variation. Some doctors waited until a child had failed three different types of blood-pressure drugs before reaching for methylene blue, while others tried it after just two. Furthermore, the safety checks before administration were not consistent. A crucial safety concern with this drug is that it can cause severe anemia in people with a specific genetic condition called G6PD deficiency, which affects how their red blood cells handle stress. In the survey, only about 22 percent of the doctors said they routinely tested for this condition before giving the drug, while more than a third said they did not test for it at all. Similarly, while about half of the doctors always checked the heart's pumping function with an ultrasound before starting, others skipped this step.
Despite the lack of a standardized approach, the doctors who used the drug generally reported positive short-term results. Nearly 60 percent observed a temporary improvement in the child's blood pressure and circulation, and about 18 percent saw a marked and lasting recovery. However, the doctors were also aware of the limitations. The most common concern among those who had used the drug was the lack of solid scientific evidence specifically for children. They noted that while the drug seemed to work in the moment, there were no large studies proving it saved lives or improved long-term outcomes for kids. For the doctors who had not used the drug, the biggest barrier was simply a lack of familiarity or experience with it, rather than a fear of the drug itself.
The study concludes that methylene blue has firmly entered the emergency toolkit for pediatric intensive care in Turkey, serving as a vital rescue option when standard treatments fail. Yet, this widespread use has outpaced the development of clear, standardized guidelines. The practice is currently defined by a patchwork of individual preferences rather than a unified national protocol. The researchers emphasize that while the drug appears to offer a lifeline in critical moments, the medical community needs better data to determine the exact dose, the right timing, and the safest way to monitor children receiving it. Until more robust studies are completed, the use of this blue dye remains a hopeful but somewhat uncertain strategy, guided more by clinical intuition and immediate necessity than by a settled science.
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