Rainbow after the storm

<span class="paragraphSection">Editor–A 71-year-old female presented with polymicrobial sepsis and mediastinitis following a dental procedure. After resuscitation with fluids and antibiotics, she required increasing doses of norepinephrine (up to 0.3 µg kg⁻¹ min⁻¹) prior to operative exploration. Point-of-care ultrasound revealed elevated cardiac filling pressures (dilated inferior vena cava without respiratory variation) and hyperdynamic cardiac function (ejection fraction >65%). Central venous pressure was 14 mmHg and central venous saturation was 70%. These findings, in addition to the requirement for high-dose intravenous vasopressors, confirmed a diagnosis of vasoplegia.<a href="#aex066-B1" class="reflinks">¹</a> An intraoperative infusion pump failure of norepinephrine resulted in profound hypotension [blood pressure (BP) 30/20 mm Hg] as measured by an indwelling arterial line. Intravenous vasopressor boluses and 100 mg of methylene blue increased systolic arterial BP to >100 mm Hg for 15 min. Because methylene blue was effective, but only for a short duration, we administered intravenous hydroxocobalamin (1 g/h) to treat her vasoplegia.<a href="#aex066-B2" class="reflinks">²</a> Her acute oliguria (<10 ml h⁻¹) was reversed and urine output increased to >500 ml h⁻¹ during the final hours of surgery.</span>

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