Evaluation of the Use of Hydroxocobalamin at a Large Academic Institution

Introduction: Hydroxocobalamin, a FDA-approved medication for cyanide poisoning, has demonstrated off-label utility in treating vasoplegia and shock due to its vasopressor-sparing effects. At Thomas Jefferson University Hospital (TJUH) and Jefferson Hospital for Neuroscience (JHN), hydroxocobalamin is authorized for intraoperative and postoperative vasoplegia in cardiac surgery when other treatments fail. However, its use may extend beyond these parameters, raising concerns regarding cost, availability, and alignment with institutional guidelines.


Methods: A retrospective medication use evaluation was conducted in patients ≥18 years who received hydroxocobalamin between September 2022 and September 2024. Primary outcome was indication for use. Secondary outcomes included norepinephrine equivalents, at administration, 30 minutes, and 3 hours post-administration; peak serum creatinine within one week; 30-day mortality; administration time; and number of doses per patient. Data was analyzed using descriptive statistics.


Results: A total of 59 patients received 74 doses. The most common indications were shock (n=42) and vasoplegia (n=30), though only 18 vasoplegia cases followed cardiac surgery. Notably, 12 patients received hydroxocobalamin for vasoplegia without concurrent cardiac surgery or ECMO, differing from institutional protocols. 71 administrations were given with concomitant vasopressor use and 37 out of 59 patients expired at 30 days. Average norepinephrine equivalents decreased from 0.20 mcg/kg/min at administration to 0.16 mcg/kg/min at 3 hours. One infusion was discontinued due to transient hypertension.


Conclusions: Hydroxocobalamin was frequently used outside the indications of use at this institution, primarily as a last-line agent in refractory shock. While associated with reduced norepinephrine equivalents from 0.2 mcg/kg/min to 0.16 mcg/kg/min at 3 hours, its use did not improve mortality outcomes. These findings underscore the need for stricter adherence to institutional guidelines and EMR improvements to determine indications. Hydroxocobalamin may have a role in refractory shock, but further studies are needed to evaluate its impact on clinical outcomes.