Figure 1.

The Emory Protocol should be deployed in the proper clinical scenario, which requires temporal proximity (~48 hr) to cardiovascular surgery with cardiopulmonary bypass support. Patients should have features and documentation of high-output shock, including a cardiac index of greater than 2.3 or a mixed venous oxygen saturation greater than or equal to 70% in conjunction with a central venous pressure greater than or equal to 8 mm Hg. Shock should be supported with catecholamines at a norepinephrine equivalence (NE) dose of approximately 0.2 µg/kg/min as well as vasopressin at a dose of greater than or equal to 0.06 U/min before third-line therapy is considered. Methylene blue (MB) should be considered the primary third-line therapy unless contraindications exist. In the event of contraindications or failure of response to MB, angiotensin II (Ang II) or hydroxocobalamin may be considered, with the choice between the two informed by the clinical situation and likelihood of adverse events. G6PD = glucose-6-phosphate dehydrogenase, IVPB = IV piggyback/IV short-term infusion, MAOI = monoamine oxidase inhibitor, MAP = mean arterial pressure, SNRI = serotonin-norepinephrine reuptake inhibitor, SSRI = selective serotonin reuptake inhibitor.