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Gramish J, Hattan A, Aljuhani O, Parameaswari PJ, Alshehri S, Korayem GB, Alkofide H, Alalawi M, Vishwakarma R, Alsowaida YS, Alqahtani R, Binorayir L, Abutaleb M, Alotaibi A, Aljohani M, Aljohani S, Samreen S, Jawhari S, Alanazi R, Al Sulaiman KA. The Impact of Midodrine Tapering Versus Nontapering Regimens on the Clinical Outcomes of Critically Ill Patients: A Retrospective Cohort Study. Ann Pharmacother 2024; 58:223-233. [PMID: 37248667 DOI: 10.1177/10600280231173290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND Midodrine has been used in the intensive care unit (ICU) setting to reduce the time to vasopressor discontinuation. The limited data supporting midodrine use have led to variability in the pattern of initiation and discontinuation of midodrine. OBJECTIVES To compare the effectiveness and safety of 2 midodrine discontinuation regimens during weaning vasopressors in critically ill patients. METHODS A retrospective cohort study was conducted at King Abdulaziz Medical City. Included patients were adults admitted to ICU who received midodrine after being unable to be weaned from intravenous vasopressors for more than 24 hours. Patients were categorized into two subgroups depending on the pattern of midodrine discontinuation (tapered dosing regimen vs. nontapered regimen). The primary endpoint was the incidence of inotropes and vasopressors re-initiation after midodrine discontinuation. RESULTS The incidence of inotropes or vasopressors' re-initiation after discontinuation of midodrine was lower in the tapering group (15.4%) compared with the non-tapering group (40.7%) in the crude analysis as well as regression analysis (odd ratio [OR] = 0.15; 95% CI = 0.03, 0.73, P = 0.02). The time required for the antihypertensive medication(s) initiation after midodrine discontinuation was longer in patients who had dose tapering (beta coefficient (95% CI): 3.11 (0.95, 5.28), P = 0.005). Moreover, inotrope or vasopressor requirement was lower 24 hours post midodrine initiation. In contrast, the two groups had no statistically significant differences in 30-day mortality, in-hospital mortality, or ICU length of stay. CONCLUSION AND RELEVANCE These real-life data showed that tapering midodrine dosage before discontinuation in critically ill patients during weaning from vasopressor aids in reducing the frequency of inotrope or vasopressor re-initiation. Application of such a strategy might be a reasonable approach among ICU patients unless contraindicated.
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Affiliation(s)
- Jawaher Gramish
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Hattan
- Pharmaceutical Care Services, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - P J Parameaswari
- Research Support Department, Research and Innovation Center, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia
| | - Shaden Alshehri
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ghazwa B Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Hadeel Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mai Alalawi
- Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, Saudi Arabia
| | | | - Yazed Saleh Alsowaida
- Department of Clinical Pharmacy, College of Pharmacy, Hail University, Hail, Saudi Arabia
| | - Rahaf Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Luluh Binorayir
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Abutaleb
- Pharmaceutical Care Services, King Fahad Central Hospital, Jazan Health, Jazan, Saudi Arabia
| | - Alanoud Alotaibi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Majidah Aljohani
- Pharmaceutical Care Division, King Saud Medical City, Riyadh, Saudi Arabia
| | - Sarah Aljohani
- Pharmaceutical Care Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sana Samreen
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Suad Jawhari
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Raghad Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khalid A Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research Platform, Riyadh, Saudi Arabia
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Athar ZM, Arshad M, Shrivastava S. Exploring the Efficacy of Midodrine for Tapering Off Vasopressors. Cureus 2024; 16:e55192. [PMID: 38558716 PMCID: PMC10981505 DOI: 10.7759/cureus.55192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Sepsis and septic shock represent critical conditions, often necessitating vasopressor support in the intensive care unit (ICU). Midodrine, an oral vasopressor, has gathered attention as a potential adjunct to vasopressor therapy, aiming to facilitate weaning and improve clinical outcomes. However, the efficacy of midodrine remains questionable, with conflicting evidence from clinical trials and meta-analyses. This article provides a comprehensive review of the literature on midodrine's role in ICU settings by gathering evidence from multicenter trials, retrospective studies, and meta-analyses. While some studies suggest a limited benefit of midodrine in expediting vasopressor weaning and reducing ICU/hospital stays, others report potential advantages, particularly in reducing mortality rates among septic shock patients. Ongoing efforts aim to address knowledge gaps surrounding midodrine's efficacy and safety.
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Affiliation(s)
| | - Mahnoor Arshad
- Internal Medicine, BronxCare Health System, New York, USA
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Lessing JK, Kram SJ, Levy JH, Grecu LM, Katz JN. Droxidopa or Atomoxetine for Refractory Hypotension in Critically Ill Cardiothoracic Surgery Patients. J Cardiothorac Vasc Anesth 2024; 38:155-161. [PMID: 37838507 DOI: 10.1053/j.jvca.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE To evaluate the effects of droxidopa or atomoxetine on intravenous (IV) vasoactive agent discontinuation in cardiothoracic intensive care unit (ICU) patients with hypotension refractory to midodrine. DESIGN Single-center, retrospective cohort study. SETTING Tertiary- and quaternary-care university teaching hospital. PARTICIPANTS Included patients who received at least 4 consecutive doses of droxidopa or atomoxetine and remained on concurrent midodrine. Patients were excluded if they received study medication before admission, had clinical deterioration after study medication initiation requiring additional vasoactives/escalation of IV vasoactive dosage for at least 12 hours, had a diagnosis of hepatorenal syndrome, were prisoners, or were pregnant. INTERVENTIONS Droxidopa, atomoxetine, or both. MEASUREMENTS AND MAIN RESULTS The primary endpoint was time to discontinuation of IV vasoactive agents after initiation of study medication, analyzed using a Kaplan-Meier estimate with the Wilcoxon method, censoring death within 24 hours of the last dose of study medication. No adjustment for repetitive analyses was made, as the analysis was hypothesis-generating. Of the 72 charts reviewed, 45 patients met inclusion criteria (18 atomoxetine, 17 droxidopa, and 10 both). There were no differences in median time to discontinuation of IV vasoactive agents (21.9 days v 8.0 days v 13.9 days, respectively; p = 0.259) or ICU or hospital length of stay between groups. A higher percentage of patients who survived to hospital discharge received both study medications or droxidopa alone (90% v 76.5%) than atomoxetine alone (44.4%, p = 0.028). CONCLUSIONS Droxidopa and atomoxetine are oral vasoactive agents with potential mechanisms to facilitate IV vasopressor weaning for patients in the ICU with hypotension refractory to midodrine, but further prospective research is needed.
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Affiliation(s)
- Julia K Lessing
- Duke University Hospital, Department of Pharmacy, Durham, NC.
| | - Shawn J Kram
- Duke University Hospital, Department of Pharmacy, Durham, NC
| | - Jerrold H Levy
- Duke University Hospital, Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham NC
| | - Loreta M Grecu
- Duke University Hospital, Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham NC
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, NC
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Sekar A, Datta D, Lakha A, Jena SS, Bansal S, Sahu RN. Oral Midodrine as an Adjunct in Rapid Weaning of Intravenous Vasopressor Support in Spinal Cord Injury. Asian J Neurosurg 2023; 18:306-311. [PMID: 37397051 PMCID: PMC10310436 DOI: 10.1055/s-0043-1769755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Background Majority of acute cervical spinal cord injury end up requiring long-term stay in intensive care unit (ICU). During the initial few days after spinal cord injury, most patients are hemodynamically unstable requiring intravenous vasopressors. However, many studies have noted that long-term intravenous vasopressors remain the main reason for prolongation of ICU stay. In this series, we report the effect of using oral midodrine in reducing the amount and duration of intravenous vasopressors in patients with acute cervical spinal cord injury. Materials and Methods Five adult patients with cervical spinal cord injury after initial evaluation and surgical stabilization are assessed for the need for intravenous vasopressors. If patients continue to need intravenous vasopressors for more than 24 hours, they were started on oral midodrine. Its effect on weaning of intravenous vasopressors was assessed. Results Patients with systemic and intracranial injury were excluded from the study. Midodrine helped in weaning of intravenous vasopressors in the first 24 to 48 hours and helped in complete weaning of intravenous vasopressors. The rate of reduction was between 0.5 and 2.0 µg/min. Conclusion Oral midodrine does have an effect in reduction of intravenous vasopressors for patients needing prolonged support after cervical spine injury. The real extent of this effect needs to be studied with collaboration of multiple centers dealing with spinal injuries. The approach seems to be a viable alternative to rapidly wean intravenous vasopressors and reduce duration of ICU stay.
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Affiliation(s)
- Arunkumar Sekar
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Debajyoti Datta
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Avinash Lakha
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Sritam Swaroop Jena
- Department of Anesthesiology, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Sumit Bansal
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
| | - Rabi Narayan Sahu
- Department of Neurosurgery, All India Institute of Medical Sciences – Bhubaneswar, Bhubaneswar, Odisha, India
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The Use of Midodrine as an Adjunctive Therapy to Liberate Patients from Intravenous Vasopressors: A Systematic Review and Meta-analysis of Randomized Controlled Studies. Cardiol Ther 2023; 12:185-195. [PMID: 36670331 PMCID: PMC9986154 DOI: 10.1007/s40119-023-00301-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 01/03/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Studies evaluating the role of midodrine as an adjunctive therapy to liberate patients with shock from intravenous (IV) vasopressors have yielded mixed results. The aim of our study was to evaluate the efficacy and safety of midodrine as an adjunctive therapy to liberate patients with shock from IV vasopressors. METHODS Electronic searches of the MEDLINE, EMBASE, and Cochrane databases through April 2022 for randomized controlled trials (RCTs) that evaluated the use of midodrine versus control in patients with shock and a low dose of IV vasopressors. The primary outcome was total IV vasopressor time, while the secondary outcomes included time-to-IV vasopressor discontinuation, IV vasopressor restart, intensive care unit (ICU) length of stay (LOS), hospital LOS, and incidence of bradycardia. RESULTS The final analysis included four RCTs with a total of 314 patients: 158 in the midodrine group and 156 in the control group, with a weighted mean age of 64 years (54.2% men). There was no significant difference in the total IV vasopressor time between the midodrine and control groups (standardized mean difference [SMD] - 0.53; 95% confidence interval [CI] - 1.38 to 0.32, p = 0.22; I2 = 92%). Also, there were no significant differences between the two groups in the time-to-IV vasopressor discontinuation (SMD - 0.05; 95% CI - 0.57 to 0.47, p = 0.09), IV vasopressor restart (19.3 vs. 28.3%; risk ratio [RR] 0.74; 95% 0.25-2.20, p = 0.59), ICU LOS (SMD - 0.49; 95% CI - 1.30 to 0.33, p = 0.24), and hospital LOS (SMD 0.01; 95% CI - 0.27 to 0.29, p = 0.92). However, compared with the control group, the midodrine group had a higher risk of bradycardia (15.3 vs. 2.1% RR 5.56; 95% CI 1.54-20.05, p = 0.01). CONCLUSIONS Among patients with vasopressor-dependent shock, midodrine was not associated with early liberation of vasopressor support or shorter ICU or hospital length of stay. Adding midodrine increased the risk of bradycardia. Further large RCTs are needed to better evaluate the efficacy and safety of midodrine in liberating patients from IV vasopressors.
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Wood AJ, Rauniyar R, Jacques A, Palmer RN, Wibrow B, Anstey MH. Oral midodrine does not expedite liberation from protracted vasopressor infusions: A case-control study. Anaesth Intensive Care 2023; 51:20-28. [PMID: 36168754 DOI: 10.1177/0310057x221105297] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Vasopressor dependence is a common problem affecting patients in the recovery phase of critical illness, often necessitating intensive care unit (ICU) admission and other interventions which carry associated risks. Midodrine is an orally administered vasopressor which is commonly used off-label to expedite weaning from vasopressor infusions and facilitate discharge from ICU. We performed a single-centre, case-control study to assess whether midodrine accelerated liberation from vasopressor infusions in patients who were vasopressor dependent. Cases were identified at the discretion of treating intensivists and received 20 mg oral midodrine every eight h from enrolment. Controls received placebo. Data on duration and dose of vasopressor infusion, haemodynamics and adverse events were collected. Between 2012 and 2019, 42 controls and 19 cases were recruited. Cases had received vasopressor infusions for a median of 94 h versus 29.3 h for controls, indicating prolonged vasopressor dependence amongst cases. Midodrine use in cases was not associated with faster weaning of intravenous (IV) vasopressors (26 h versus 24 h for controls, P = 0.51), ICU or hospital length of stay after adjustment for confounders. Midodrine did not affect mean heart rate but was associated with bradycardia. This case-control study demonstrates that midodrine has limited efficacy in expediting weaning from vasopressor infusions in patients who have already received relatively prolonged courses of these infusions.
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Affiliation(s)
- Alexander Jt Wood
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,University of Western Australia, School of Medicine, Perth, Australia
| | - Rashmi Rauniyar
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Angela Jacques
- Institute for Health Research, 3431The University of Notre Dame Australia, Fremantle, Australia.,Department of Research, Sir Charles Gairdner Hospital, Perth, Australia
| | - Robert N Palmer
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Bradley Wibrow
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,University of Western Australia, School of Medicine, Perth, Australia
| | - Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,University of Western Australia, School of Medicine, Perth, Australia.,Curtin University, School of Public Health, Perth, Australia
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Costa-Pinto R, Jones DA, Udy AA, Warrillow SJ, Bellomo R. Midodrine use in critically ill patients: a narrative review. CRIT CARE RESUSC 2022; 24:298-308. [PMID: 38047013 PMCID: PMC10692611 DOI: 10.51893/2022.4.r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Midodrine is a peripherally acting, oral α-agonist that is increasingly used in intensive care units despite conflicting evidence for its effectiveness. It has pharmacological effects on blood vessels as well as pupillary, cardiac, renal, gastrointestinal, genitourinary, lymphatic and skin tissue. It has approval for use as a treatment for orthostatic hypotension, but a surge in interest over the past decade has prompted its use for a growing number of off-label indications. In critically ill patients, midodrine has been used as either an adjunctive oral therapy to wean vasoplegic patients off low dose intravenous vasopressor infusions, or as an oral vasopressor agent to prevent or minimise the need for intravenous infusion. Clinical trials have mostly focused on midodrine as an intravenous vasopressor weaning agent. Early retrospective studies supported its use for this indication, but more recent randomised controlled trials have largely refuted this practice. Key questions remain on its role in managing critically ill patients before intensive care admission, during intensive care stay, and following discharge. This narrative review presents a comprehensive overview of midodrine use for the critical care physician and highlights why lingering questions around ideal patient selection, dosing, timing of initiation, and efficacy of midodrine for critically ill patients remain unanswered.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Daryl A. Jones
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew A. Udy
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Stephen J. Warrillow
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
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Kamaleldin M, Kilcommons S, Opgenorth D, Fiest K, Karvellas CJ, Kutsogiannis J, Lau V, MacIntyre E, Rochwerg B, Senaratne J, Slemko J, Sligl W, Wang X, Bagshaw SM, Rewa OG. Midodrine therapy for vasopressor dependent shock in the intensive care unit: a protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e064060. [PMID: 36418124 PMCID: PMC9684992 DOI: 10.1136/bmjopen-2022-064060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Intensive care unit (ICU) lengths of stay are modified by ongoing need for haemodynamic support in critically ill patients. This is most commonly provided by intravenous vasopressor therapy. Midodrine has been used as an oral agent for haemodynamic support in patients with orthostatic hypotension or cirrhosis. However, its efficacy in treating shock in the ICU, particularly for patients weaning from intravenous vasopressors, remains uncertain. The objective of this systematic review is to determine the efficacy of midodrine in vasopressor dependent shock. METHODS AND ANALYSIS We will search Ovid MEDLINE, Ovid Embase, CINAHL and Cochrane Library for observational trials and randomised controlled trials evaluating midodrine in critically ill patients from inception to 21 April 2022. We will also review unpublished data and relevant conference abstracts. Outcomes will include ICU length of stay, duration of intravenous vasopressor support, ICU mortality, hospital mortality, hospital length of stay and rates of ICU readmission. Data will be analysed in aggregate, where appropriate. We will evaluate risk of bias using the modified Cochrane tool and certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations methodology. We will perform trial sequential analysis for the outcome of ICU length of stay. ETHICS AND DISSEMINATION Ethics approval is not required as primary data will not be collected. Findings of this review will be disseminated through peer-related publication and will inform future clinical trials. PROSPERO REGISTRATION NUMBER CRD42021260375.
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Affiliation(s)
| | | | - Dawn Opgenorth
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Constantine Jason Karvellas
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Jim Kutsogiannis
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Vincent Lau
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Erika MacIntyre
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Bram Rochwerg
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Janek Senaratne
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Jocelyn Slemko
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Wendy Sligl
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Statistical and Analytical Methods, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sean M Bagshaw
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Oleksa G Rewa
- University of Alberta, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
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Alseoudy MM, Nasr MO, Abdelsalam TA. Efficacy of Preoperative Oral Midodrine in Preventing Hypotension After Spinal Anesthesia in Young Adults: A Randomized Controlled Trial. Anesth Analg 2022; 135:1089-1096. [PMID: 35950781 DOI: 10.1213/ane.0000000000006173] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Midodrine was effectively used for prophylaxis against hypotensive syndromes such as postural hypotension and intradialytic hypotension, and during the recovery phase of septic shock. In our study, we aimed to assess the efficacy of prophylactic administration of midodrine tablets before spinal anesthesia in reducing the occurrence of hypotension. METHODS This randomized placebo-controlled study embraced 67 patients aged 18 to 40 years undergoing elective knee surgery under spinal anesthesia. Patients were randomized to midodrine group (given 10-mg tablets of midodrine) or placebo group (given placebo tablets), and tablets were administered 1 hour before spinal anesthesia (intrathecal injection of 12.5-mg 0.5% hyperbaric bupivacaine and 15-μg fentanyl). The primary outcome was the occurrence of hypotension, defined as a systolic blood pressure <90 mm Hg or <80% of baseline. Secondary outcomes were hemodynamic characteristics (mean arterial pressure [MAP] and heart rate [HR]) after spinal anesthesia, ephedrine dose, and occurrence of complications including bradycardia, vasovagal attacks, reactive hypertension nausea, vomiting, and shivering. RESULTS The number of patients who became hypotensive after spinal anesthesia was 5 (14.7%) in midodrine group versus 14 (42.4%) in the placebo group; relative risk (95% confidence interval) was 0.35 (0.14-0.85) ( P = .021). The median (interquartile range) total dose of ephedrine was significantly lower in midodrine group 0 (0-10) mg than in placebo group (0 (0-15) mg; the Hodges-Lehmann median difference (95% confidence interval) was 0 (0-5) mg ( P = .015). For MAP data, the group × time interaction was significant ( P = .038), and the MAP was significantly lower in the placebo group than in the midodrine group after intrathecal injection at 2 minutes ( P = .047), 10 minutes ( P = .045), 15 minutes ( P < .001), 20 minutes ( P = .007), 30 minutes ( P =.013), 45 minutes ( P = .029), 60 minutes ( P = .029), and at the end of surgery ( P < .001). For HR data, the group × time interaction was nonsignificant ( P = .807), and the difference in means (95% confidence interval) between groups collapsing over time was -1.4 (-3.1 to 0.2) beats/min ( P = .096). There was no significant difference between the 2 groups regarding the occurrence of complications. CONCLUSIONS Prophylactic administration of 10-mg midodrine tablets before spinal anesthesia is an effective method in the prevention of hypotension in young adult patients undergoing elective orthopedic knee surgery.
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Affiliation(s)
- Mahmoud Mohammed Alseoudy
- From the Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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10
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Riker RR, Gagnon DJ. Letter to the Editor: "Midodrine to liberate ICU patients from intravenous vasopressors: Another negative fixed-dose trial". J Crit Care 2022; 69:153995. [PMID: 35152142 PMCID: PMC9064955 DOI: 10.1016/j.jcrc.2022.153995] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/18/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Richard R. Riker
- Department of Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, Maine 04102, USA
| | - David J. Gagnon
- Departments of Pharmacy and Critical Care, Maine Medical Center, 22 Bramhall Street, Portland, Maine 04102, USA
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Opgenorth D, Baig N, Fiest K, Karvellas C, Kutsogiannis J, Lau V, Macintyre E, Senaratne J, Slemko J, Sligl W, Wang X, Bagshaw SM, Rewa OG. LIBERATE: a study protocol for midodrine for the early liberation from vasopressor support in the intensive care unit (LIBERATE): protocol for a randomized controlled trial. Trials 2022; 23:194. [PMID: 35246227 PMCID: PMC8896263 DOI: 10.1186/s13063-022-06115-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/15/2022] [Indexed: 12/04/2022] Open
Abstract
Background Intravenous (IV) vasopressors to support hemodynamics are a primary indication for intensive care unit (ICU) admission. Utilization of oral vasopressor therapy may offer an alternative to IV vasopressor therapy in the ICU, thus decreasing the need for ICU admission. Oral vasopressors, such as midodrine, have been used for hemodynamic support in non-critically ill patients, but their evaluation in critically ill patients to potentially spare IV vasopressor therapy has been limited. Methods The LIBERATE study will be a multicenter, parallel-group, blinded, randomized placebo-controlled trial. It will recruit adult (i.e., age ≥ 18 years) critically ill patients receiving stable or decreasing doses of IV vasopressors. Eligible patients will be randomized to receive either midodrine 10 mg administered enterally every 8 h or placebo until 24 h post-discontinuation of IV vasopressors. The primary outcome will be ICU length of stay. Secondary outcomes include all-cause mortality at 90 days, hospital length of stay, length of IV vasopressor support, re-initiation of IV vasopressors, rates of ICU readmission, and occurrence of AEs. Health economic outcomes including ICU, hospital and healthcare costs, and cost-effectiveness will be evaluated. Pre-planned subgroup analyses include age, sex, frailty, severity of illness, etiology of shock, and comorbid conditions. Discussion LIBERATE will rigorously evaluate the effect of oral midodrine on duration of ICU stay and IV vasopressor support in critically ill patients. Trial registration ClinicalTrials.gov NCT05058612. Registered on September 28, 2021 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06115-0.
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Affiliation(s)
- Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Nadia Baig
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Constantine Karvellas
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jim Kutsogiannis
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Vincent Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Erika Macintyre
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Jocelyn Slemko
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Wendy Sligl
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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12
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Smith SE, Peters NA, Floris LM, Patterson JM, Hawkins WA. Putting midodrine on the MAP: An approach to liberation from intravenous vasopressors in vasodilatory shock. Am J Health Syst Pharm 2022; 79:1047-1055. [PMID: 35235946 DOI: 10.1093/ajhp/zxac069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Prolonged duration of intravenous (IV) vasopressor dependence in critically ill adult patients with vasodilatory shock results in increased length of stay in both the intensive care unit (ICU) and hospital, translating to higher risk of infection, delirium, immobility, and cost. Acceleration of vasopressor liberation can aid in reducing these risks. Midodrine is an oral α1-adrenergic receptor agonist that offers a potential means of liberating patients from IV vasopressor therapy. This clinical review summarizes primary literature and proposes a clinical application for midodrine in the recovery phase of vasodilatory shock. SUMMARY Five studies with a total of over 1,000 patients conducted between 2011 and 2021 were identified. In observational studies, midodrine administration was demonstrated to lead to faster time to liberation from IV vasopressor therapy and shorter ICU length of stay in patients recovering from vasodilatory shock. These findings were not replicated in a prospective, multicenter, randomized controlled trial. In this review, literature evaluating midodrine use for IV vasopressor liberation is summarized and study limitations are discussed. CONCLUSION On the basis of this review of current literature, recommendations are provided on selecting appropriate candidates for adjunctive midodrine in the recovery phase of vasodilatory shock and considerations are discussed for safely and effectively initiating, titrating, and discontinuing therapy.
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Affiliation(s)
- Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Nicholas A Peters
- Department of Pharmacy, Indiana University Health, Indianapolis, IN, USA
| | - Lauren M Floris
- Department of Pharmacy, Atrium Navicent Health Medical Center, Macon, GA, USA
| | | | - W Anthony Hawkins
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, and Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Albany, GA, USA
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Costa-Pinto R, Yong ZT, Yanase F, Young C, Brown A, Udy A, Young PJ, Eastwood G, Bellomo R. A pilot, feasibility, randomised controlled trial of midodrine as adjunctive vasopressor for low-dose vasopressor-dependent hypotension in intensive care patients: The MAVERIC study. J Crit Care 2022; 67:166-171. [PMID: 34801917 DOI: 10.1016/j.jcrc.2021.11.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/15/2021] [Accepted: 11/03/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the feasibility and physiological efficacy of adjunctive midodrine in patients with vasopressor-dependent hypotension. MATERIALS AND METHODS This was a pilot, open label, randomised controlled trial. Patients were enrolled from two tertiary intensive care units on low dose intravenous vasopressor therapy for more than 24 h. We randomly assigned patients to receive either adjunctive midodrine (10 mg every 8 h) or usual care. The primary efficacy outcome was time to cessation of intravenous vasopressor therapy. Secondary outcomes included protocol compliance, ICU and hospital length of stay. RESULTS We screened 381 patients over 22-months and enrolled 62 (32 in midodrine group, 30 in usual care group). Median time to cessation of vasopressor infusion was 16.5 h for midodrine vs 19 h for usual care (p = 0.22). Time in ICU (50 [25.50, 74.00] hours for midodrine v 59 [38.50, 93.25] hours for usual care, p = 0.14) and hospital length of stay (9 days vs. 7.5 days, p = 0.92) were similar. Protocol compliance was 96.9%. One patient ceased midodrine early due to symptomatic bradycardia. CONCLUSIONS Adjunctive midodrine therapy was feasible with acceptable compliance, duration of therapy, and safety profile. However, at the chosen dose, there was no evidence of physiological or clinical efficacy.
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Affiliation(s)
- Rahul Costa-Pinto
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia.
| | - Zhen-Ti Yong
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Chelsea Young
- Department of Intensive Care, Wellington Regional Hospital, 49 Riddiford Street, Newtown, Wellington, New Zealand
| | - Alastair Brown
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Andrew Udy
- Department of Intensive Care, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Paul J Young
- Department of Intensive Care, Wellington Regional Hospital, 49 Riddiford Street, Newtown, Wellington, New Zealand; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Medical Research Institute of New Zealand, Private Bag, 7902, Wellington, New Zealand; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Critical Care, Department of Medicine, the University of Melbourne, Parkville, Victoria, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia
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14
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Midodrine improves clinical and economic outcomes in patients with septic shock: a randomized controlled clinical trial. Ir J Med Sci 2022; 191:2785-2795. [PMID: 34981420 DOI: 10.1007/s11845-021-02903-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Prolonged use of intravenous (IV) vasopressors in patients with septic shock can lead to deleterious effects. AIMS This study assessed the impact of midodrine administration on weaning off IV vasopressors and its economic value. METHODS It is a prospective randomized controlled study of 60 resuscitated patients with septic shock who demonstrated clinical stability on low-dose IV vasopressors for at least 24 h. Participants were randomized into two groups: norepinephrine (IV norepinephrine) and midodrine (IV norepinephrine + oral midodrine 10 mg thrice a day). A cost comparison was applied based on the outcomes of both groups. RESULTS The median duration of norepinephrine administration in the midodrine and norepinephrine groups was 4 and 6 days, respectively (p = 0.001). Norepinephrine weaning time was significantly less in the midodrine versus norepinephrine groups (26 and 78.5 h, respectively; p < 0.001). Mortality was 43.3% versus 73.3% in the midodrine and norepinephrine groups, respectively (p = 0.018). The mean length of stay was comparable in the two groups. The midodrine group showed cost-saving results versus the norepinephrine group. CONCLUSION The use of midodrine in septic shock patients significantly reduced IV norepinephrine duration, weaning period during the septic shock recovery phase, and mortality. Thus, the use of midodrine is dominant with less cost, better outcome and a cost-saving option in terms of budget impact analysis. This study was registered at clinicaltrials.gov (NCT 03,911,817) on April 11, 2019.
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Farhat R, Minoff J, Burke S, Patolia S. Recommended Reading from Saint Louis University School of Medicine Fellows. Am J Respir Crit Care Med 2021; 204:1473-1475. [PMID: 34699334 DOI: 10.1164/rccm.202103-0685rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Rania Farhat
- Saint Louis University, 7547, Saint Louis, Missouri, United States
| | - Jennifer Minoff
- Saint Louis University, 7547, Saint Louis, Missouri, United States
| | - Shannon Burke
- Saint Louis University, 7547, Saint Louis, Missouri, United States
| | - Setu Patolia
- Saint Louis University, 7547, Pulmonary and Critical Care, Saint Louis, Missouri, United States;
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Oral Midodrine Administration During the First 24 Hours of Sepsis to Reduce the Need of Vasoactive Agents: Placebo-Controlled Feasibility Clinical Trial. Crit Care Explor 2021; 3:e0382. [PMID: 33977276 PMCID: PMC8104269 DOI: 10.1097/cce.0000000000000382] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives: Our preliminary data and observational studies suggested an increasing “off label” use of oral midodrine as a vasopressor sparing agent in various groups of critically ill patients, including those with sepsis. We designed this clinical trial to evaluate the feasibility of use of midodrine hydrochloride in early sepsis to reduce the duration for IV vasopressors and decrease ICU and hospital length of stay. Design: Pilot, two-center, placebo-controlled, double blinded randomized clinical trial. Setting: Medical ICUs at Mayo Clinic Rochester and Cleveland Clinic Abu Dhabi were the study sites. Patients and Methods: Adult patients (≥ 18 yr old) were included within 24 hours of meeting the Sepsis-3 definition if the mean arterial pressure remained less than 70 mm Hg despite receiving timely antibiotics and initial IV fluid bolus of 30 cc/kg. Intervention: Three doses of 10 mg midodrine versus placebo were administered. Measurements and Main Results: Total 32 patients were randomized into midodrine (n = 17) and placebo groups (n = 15). There were no major differences in baseline variables between the groups except for higher baseline creatinine in the midodrine group (2.0 ± 0.9 mg/dL) versus placebo group (1.4 ± 0.6 mg /dL), p = 0.03. The median duration of IV vasopressor requirement was 14.5 ± 8.1 hours in midodrine group versus 18.8 ± 7.1 hours in the placebo group, p value equals to 0.19. Patients in the midodrine group needed 729 ± 963 norepinephrine equivalent compared with 983 ± 1,569 norepinephrine equivalent in the placebo group, p value equals to 0.59. ICU length of stay was 2.29 days (interquartile range, 1.65–3.9 d) in the midodrine group, compared with 2.45 days (interquartile range, 1.6–3.2 d) in the placebo group, p value equals to 0.36. No serious adverse events were observed in either group. Conclusions: Phase II clinical trial powered for clinical outcomes (duration of vasopressor use, need for central venous catheter, and ICU and hospital length of stay) is justified.
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17
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Abstract
In practice, midodrine has been used to reduce IV vasopressor requirements and decrease ICU length of stay. However, recent publications have failed to show clinical success when midodrine was administered every 8 hours. One possible reason for the lack of clinical efficacy at this dosing interval may be the pharmacokinetic properties of midodrine that support a more frequent dosing interval. Here, we report our institutional experience with midodrine at a dosing frequency of every 6 hours. Design Single, quaternary academic medical center, retrospective, descriptive study. Setting Floor and ICU patients admitted to Mayo Clinic, Rochester, from May 7, 2018, to September 30, 2020. Patients Adult patients with an order for midodrine with a dosing frequency of "every 6 hours" or "four times daily" were eligible for inclusion. Interventions No intervention performed. All data were abstracted retrospectively from the electronic medical record. Measurements and Main Results Forty-four unique patients were identified that met inclusion criteria. Patients were an average of 65 years and 63.6% were male. The individual doses of midodrine ranged from 5 to 20 mg. Twenty-three patients (52.3%) were receiving IV vasopressors at the time midodrine was ordered every 6 hours. Vasopressor requirements decreased from an average of 0.10 norepinephrine equivalents 24 hours prior to the every 6-hour order to 0.05 norepinephrine equivalents 24 hours after an order for midodrine every 6 hour was placed. Conclusions Increasing the dosing frequency of midodrine to every 6 hours may optimize its pharmacokinetic profile without compromising safety. This midodrine dosing frequency should be prospectively evaluated as a primary strategy for accelerated IV vasopressor wean.
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18
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Davoudi-Monfared E, Mohammadi M, Khoshavi M, Khalili H. The effect of midodrine on lactate clearance in patients with septic shock: a pilot study. J Comp Eff Res 2021; 10:673-683. [PMID: 33860672 DOI: 10.2217/cer-2020-0238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: The effect of midodrine on lactate clearance has not been assessed in critically ill patients yet. Objective: The goal of this study was to assess the effect of adjunctive midodrine therapy on lactate clearance in patients with septic shock. Materials & methods: Patients with septic shock were assigned to receive either adjunctive midodrine 10 mg three-times a day for 5 days (midodrine group = 15 patients) or not (control group = 13 patients). Results: The lactate clearance was significantly faster in the midodrine group than the control group (p = 0.049) with a large effect size (ηp2 = 0.141). Conclusion: When midodrine was added to intravenous vasopressors, it significantly accelerated lactate clearance in patients with septic shock. Trial registration number: IRCT20100228003449N25 (Clinicaltrials.gov).
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Affiliation(s)
- Effat Davoudi-Monfared
- Department of Pharmacotherapy, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Meysam Khoshavi
- Department of Cardiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Pharmacotherapy, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Santer P, Eikermann M. High-dose midodrine is not effective for treatment of persistent hypotension in the intensive care unit. Intensive Care Med 2021; 47:252-253. [PMID: 33416917 DOI: 10.1007/s00134-020-06333-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA. .,Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
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20
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Midodrine administration during critical illness: fixed-dose or titrate to response? Intensive Care Med 2020; 47:249-251. [PMID: 33237345 DOI: 10.1007/s00134-020-06321-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 10/22/2022]
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21
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Tremblay JA, Laramée P, Lamarche Y, Denault A, Beaubien-Souligny W, Frenette AJ, Kontar L, Serri K, Charbonney E. Potential risks in using midodrine for persistent hypotension after cardiac surgery: a comparative cohort study. Ann Intensive Care 2020; 10:121. [PMID: 32926256 PMCID: PMC7490305 DOI: 10.1186/s13613-020-00737-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/06/2020] [Indexed: 12/16/2022] Open
Abstract
Background Persistent hypotension is a frequent complication after cardiac surgery with cardiopulmonary bypass (CPB). Midodrine, an orally administered alpha agonist, could potentially reduce intravenous vasopressor use and accelerate ICU discharge of otherwise stable patients. The main objective of this study was to explore the clinical impacts of administering midodrine in patients with persistent hypotension after CPB. Our hypothesis was that midodrine would safely accelerate ICU discharge and be associated with more days free from ICU at 30 days. Results We performed a retrospective cohort study that included all consecutive patients having received midodrine while being on vasopressor support in the ICU within the first week after cardiac surgery with CPB, between January 2014 and January 2018 at the Montreal Heart Institute. A contemporary propensity score matched control group that included patients who presented similarly prolonged hypotension after cardiac surgery was formed. After matching, 74 pairs of patients (1:1) fulfilled inclusion criteria for the study and control groups. Midodrine use was associated with fewer days free from ICU (25.8 [23.7–27.1] vs 27.2 [25.9–28] days, p = 0.002), higher mortality (10 (13.5%) vs 1 (1.4%), p = 0.036) and longer ICU length of stay (99 [68–146] vs 68 [48–99] hours, p = 0.001). There was no difference in length of intravenous vasopressors (63 [40–87] vs 44 [26–66] hours, p = 0.052), rate of ICU readmission (6 (8.1%) vs 2 (2.7%), p = 0.092) and occurrence of severe kidney injury (11 (14.9%) vs 10 (13.5%) patients, p = 0.462) between groups. Conclusion The administration of midodrine for sustained hypotension after cardiac surgery with CPB was associated with fewer days free from ICU and higher mortality. Routine prescription of midodrine to hasten ICU discharge after cardiac surgery should be used with caution until further prospective studies are conducted.
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Affiliation(s)
- Jan-Alexis Tremblay
- Critical Care, Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada.
| | - Philippe Laramée
- Emergency Medicine, Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada
| | - Yoan Lamarche
- Critical Care, Institut de Cardiologie de Montréal, 5000 Rue Bélanger, Montréal, QC, H3T 1J4, Canada.,Cardiac Surgery, Institut de Cardiologie de Montréal, 5000 Rue Bélanger, Montréal, QC, H3T 1J4, Canada
| | - André Denault
- Critical Care, Institut de Cardiologie de Montréal, 5000 Rue Bélanger, Montréal, QC, H3T 1J4, Canada
| | | | - Anne-Julie Frenette
- Critical Care, Hôpital du Sacré-Cœur de Montréal, 5400 Boul Gouin O, Montréal, QC, H3T 1J4, Canada
| | - Loay Kontar
- Critical Care, Institut de Cardiologie de Montréal, 5000 Rue Bélanger, Montréal, QC, H3T 1J4, Canada
| | - Karim Serri
- Critical Care, Hôpital du Sacré-Cœur de Montréal, 5400 Boul Gouin O, Montréal, QC, H3T 1J4, Canada
| | - Emmanuel Charbonney
- Critical Care, Hôpital du Sacré-Cœur de Montréal, 5400 Boul Gouin O, Montréal, QC, H3T 1J4, Canada
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Santer P, Anstey MH, Patrocínio MD, Wibrow B, Teja B, Shay D, Shaefi S, Parsons CS, Houle TT, Eikermann M. Effect of midodrine versus placebo on time to vasopressor discontinuation in patients with persistent hypotension in the intensive care unit (MIDAS): an international randomised clinical trial. Intensive Care Med 2020; 46:1884-1893. [PMID: 32885276 DOI: 10.1007/s00134-020-06216-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/12/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE ICU discharge is often delayed by a requirement for intravenous vasopressor medications to maintain normotension. We hypothesised that the administration of midodrine, an oral α1-adrenergic agonist, as adjunct to standard treatment shortens the duration of intravenous vasopressor requirement. METHODS In this multicentre, randomised, controlled trial including three tertiary referral hospitals in the US and Australia, we enrolled adult patients with hypotension requiring a single-agent intravenous vasopressor for ≥ 24 h. Subjects received oral midodrine (20 mg) or placebo every 8 h in addition to standard care until cessation of intravenous vasopressors, ICU discharge, or occurrence of adverse events. The primary outcome was time to vasopressor discontinuation. Secondary outcomes included time to ICU discharge readiness, ICU and hospital lengths of stay, and ICU readmission rates. RESULTS Between October 2012 and June 2019, 136 participants were randomised, of whom 132 received the allocated intervention and were included in the analysis (modified intention-to-treat approach). Time to vasopressor discontinuation was not different between midodrine and placebo groups (median [IQR], 23.5 [10-54] vs 22.5 [10.4-40] h; difference, 1 h; 95% CI - 10.4 to 12.3 h; p = 0.62). No differences in secondary endpoints were observed. Bradycardia occurred more often after midodrine administration (5 [7.6%] vs 0 [0%], p = 0.02). CONCLUSION Midodrine did not accelerate liberation from intravenous vasopressors and was not effective for the treatment of hypotension in critically ill patients.
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Affiliation(s)
- Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Matthew H Anstey
- Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia
| | - Maria D Patrocínio
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Bradley Wibrow
- Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia
| | - Bijan Teja
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Denys Shay
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Charles S Parsons
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA. .,Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
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Viglianti EM, Bagshaw SM, Bellomo R, McPeake J, Molling DJ, Wang XQ, Seelye S, Iwashyna TJ. Late Vasopressor Administration in Patients in the ICU: A Retrospective Cohort Study. Chest 2020; 158:571-578. [PMID: 32278780 PMCID: PMC7417379 DOI: 10.1016/j.chest.2020.02.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 01/31/2020] [Accepted: 02/16/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Little is known about the prevalence, predictors, and outcomes of late vasopressor administration which evolves after admission to the ICU. RESEARCH QUESTION What is the epidemiology of late vasopressor administration in the ICU? STUDY DESIGN AND METHODS We retrospectively studied a cohort of veterans admitted to the Veterans Administration ICUs for ≥ 4 days from 2014 to 2017. The timing of vasopressor administration was categorized as early (only within the initial 3 days), late (on day 4 or later and none on day 3), and continuous (within the initial 2 days through at least day 4). Regressions were performed to identify patient factors associated with late vasopressor administration and the timing of vasopressor administration with posthospitalization discharge mortality. RESULTS Among the 62,206 hospitalizations with at least 4 ICU days, late vasopressor administration occurred in 5.5% (3,429 of 62,206). Patients with more comorbidities (adjusted OR [aOR], 1.02 per van Walraven point; 95% CI, 1.02-1.03) and worse severity of illness on admission (aOR, 1.01 per percentage point risk of death; 95% CI, 1.01-1.02) were more likely to receive late vasopressor therapy. Nearly 50% of patients started a new antibiotic within 24 h of receiving late vasopressor therapy. One-year mortality after survival to discharge was higher for patients with continuous (adjusted hazard ratio [aHR], 1.48; 95% CI, 1.33-1.65) and late vasopressor administration (aHR, 1.26; 95% CI, 1.15-1.38) compared with only early vasopressor administration. INTERPRETATION Late vasopressor administration was modestly associated with comorbidities and admission illness severity. One-year mortality was higher among those who received late vasopressor administration compared with only early vasopressor administration. Research to understand optimization of late vasopressor therapy administration may improve long-term mortality.
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Affiliation(s)
- Elizabeth M Viglianti
- Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
| | - Joanne McPeake
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, Scotland; Intensive Care Unit, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, Scotland
| | - Daniel J Molling
- HSR&D Center for Innovation, Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
| | - Xiao Qing Wang
- Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI
| | - Sarah Seelye
- HSR&D Center for Innovation, Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
| | - Theodore J Iwashyna
- Department of Internal Medicine Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI; HSR&D Center for Innovation, Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI; Institute for Social Research, Ann Arbor, MI
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Rizvi MS, Nei AM, Gajic O, Mara KC, Barreto EF. Continuation of Newly Initiated Midodrine Therapy After Intensive Care and Hospital Discharge: A Single-Center Retrospective Study. Crit Care Med 2020; 47:e648-e653. [PMID: 31107279 DOI: 10.1097/ccm.0000000000003814] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Midodrine is an α1-agonist approved for orthostatic hypotension. Recently, it has received attention as an oral vasopressor to facilitate ICU discharge. The purpose of this study was to identify the incidence of continuation of newly initiated midodrine upon ICU and hospital discharge and identify risk factors associated with its occurrence. DESIGN Single-center retrospective study. SETTING ICU patients from January 2011 to October 2016 at Mayo Clinic, Rochester. PATIENTS Adult patients admitted to any ICU who received new midodrine for hypotension and survived to discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, 1,010 patients were newly started on midodrine and survived to ICU discharge. Midodrine was continued in 67% (672/1,010) of patients at ICU discharge. Admission to cardiovascular surgery ICU and mixed medical/surgical ICU was a risk factor for midodrine continuation at ICU discharge (odds ratio, 3.94 [2.50-6.21] and 2.03 [1.29-3.20], respectively). At hospital discharge, 34% (311/909) of patients were continued on midodrine therapy. History of congestive heart failure predicted midodrine continuation at hospital discharge (odds ratio, 1.49 [1.05-2.12]). Hypertension and use of mechanical ventilation were associated with a decreased odds of midodrine prescription at both ICU and hospital discharge. Of those discharged from the ICU or hospital on midodrine, 50% were concomitantly prescribed antihypertensives. Discharge from the ICU on midodrine was associated with a significantly shorter ICU length of stay (7.5 ± 8.9 vs 10.6 ± 13.4 d) and reduced risk of in-hospital mortality (hazard ratio, 0.47 [95% CI, 0.32-0.70]; p < 0.001), despite no difference in baseline severity of illness scores. In contrast, patients discharged from the hospital on midodrine had a higher risk of 1-year mortality (hazard ratio, 1.60 [95% CI, 1.26-2.04]; p < 0.001). CONCLUSIONS This study established a high prevalence of midodrine continuation in transitions of care. The risks and benefits of this practice remain unclear. Future studies should explore the impact of this practice on patient outcomes and resource utilization. These insights could be used to model interventions for proper tapering, discontinuation, or follow-up of new start midodrine.
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Affiliation(s)
- Mahrukh S Rizvi
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Andrea M Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Erin F Barreto
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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25
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Tchen S, Sullivan JB. Clinical utility of midodrine and methylene blue as catecholamine-sparing agents in intensive care unit patients with shock. J Crit Care 2020; 57:148-156. [PMID: 32145658 DOI: 10.1016/j.jcrc.2020.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/29/2020] [Accepted: 02/17/2020] [Indexed: 02/07/2023]
Abstract
Shock is common in the intensive care unit, affecting up to one third of patients. Treatment of shock is centered upon managing hypotension and ensuring adequate perfusion via administration of fluids and catecholamine vasopressors. Due to the risks associated with catecholamine vasopressors, interest has grown in using catecholamine-sparing agents such as midodrine and methylene blue. Midodrine is an orally administered alpha-1 adrenergic agonist while methylene blue is an intravenously administered blue dye used to restore vascular tone and increase blood pressure. Separate MEDLINE, Scopus, and Embase database searches were conducted to assess literature revolving around these agents. Examples of search terms included "midodrine", "methylene blue", "critically ill", "shock", and "catecholamine-sparing." Several studies have evaluated their use in patients with shock and found potential benefits in terms of causing significant elevations in blood pressure and hastening catecholamine vasopressor discontinuation with few adverse effects; however, robust evidence is lacking for these off-label indications. Because of the variety of dosing strategies used and the incongruences between patient populations, it is also challenging to define finite recommendations. This review aims to summarize current evidence for the use of midodrine and methylene blue as catecholamine-sparing agents in critically ill patients with resolving or refractory shock.
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Affiliation(s)
- Stephanie Tchen
- Froedtert Hospital, 9200 W Wisconsin Ave, Milwaukee, WI 53226, United States of America.
| | - Jesse B Sullivan
- Fairleigh Dickinson University School of Pharmacy & Health Sciences, Pharmacy Practice, 230 Park Ave, M-SP1-01, Florham Park, NJ 07932, United States of America.
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26
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Vu T, Vallabh M, Laine G. Adrenal Insufficiency and Response to Stress Dose Hydrocortisone in Patients With Cirrhosis and Vasopressor Dependency Using Cirrhosis-Specific Cortisol Thresholds. Ann Pharmacother 2020; 54:742-749. [PMID: 31928081 DOI: 10.1177/1060028019900266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Cortisol thresholds defining adrenal insufficiency (AI) in some cirrhosis-specific studies differ from those recommended by the SCCM/ESICM (Society of Critical Care Medicine/European Society of Intensive Care Medicine) guidelines, which may influence treatment decisions. Objective: To determine if stress-dose hydrocortisone (HC) improves outcomes in vasopressor-dependent patients meeting cirrhosis-specific criteria for AI. Methods: In this retrospective study, AI was defined using criteria from 2 studies in critically ill cirrhosis patients showing mortality reduction with HC (random cortisol <20 µg/dL, or if a standard-dose cosyntropin test was performed, baseline cortisol <15 µg/dL or delta cortisol <9 µg/dL if baseline = 15-34 µg/dL). Use of HC was at the discretion of the intensivist. The primary endpoint was days of vasopressor therapy. Secondary endpoints included hospital mortality and newly acquired infections. Sixty-four patients were evaluated; 40 patients received HC and 24 did not. Results: Mean random cortisol was significantly lower in the HC group (9.8 ± 3.2 vs 12.0 ± 3.7 µg/dL, P = 0.04). Delta cortisol also tended to be lower in the HC group (8.2 ± 4.4 vs 11.3 ± 6.4 µg/dL, P = 0.25). Patients in the HC group exhibited significantly fewer median days of vasopressor therapy (4.0 [2.0-7.0] vs 7.0 [4.2-10.8], P = 0.006), lower mortality (22.5% vs 50%, P = 0.02), and a similar incidence of newly acquired infections. Conclusion and Relevance: The use of HC in patients meeting cirrhosis-specific criteria for AI resulted in significantly shorter duration of vasopressor therapy, lower mortality, and no increased risk of infection. Use of traditional AI definitions may exclude patients with cirrhosis that could benefit from HC therapy.
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Affiliation(s)
- Trenton Vu
- CHI St. Luke's Health Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Meghna Vallabh
- CHI St. Luke's Health Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Greg Laine
- CHI St. Luke's Health Baylor St. Luke's Medical Center, Houston, TX, USA
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Hammond DA, Painter JT, Meena N. Incidence of Clinically Significant Hypotension Stratified by Vasopressin Duration. J Intensive Care Med 2019; 34:77-78. [PMID: 30798676 DOI: 10.1177/0885066617745809] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Drayton A Hammond
- 1 Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Jacob T Painter
- 2 Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Nikhil Meena
- 3 Department of Pulmonary/Critical Care, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, USA
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28
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Hawkins WA, Smith SE, Newsome AS, Carr JR, Bland CM, Branan TN. Fluid Stewardship During Critical Illness: A Call to Action. J Pharm Pract 2019; 33:863-873. [PMID: 31256705 PMCID: PMC7675763 DOI: 10.1177/0897190019853979] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Intravenous fluids (IVFs) are the most common drugs administered in the intensive care unit. Despite the ubiquitous use, IVFs are not benign and carry significant risks associated with under- or overadministration. Hypovolemia is associated with decreased organ perfusion, ischemia, and multi-organ failure. Hypervolemia and volume overload are associated with organ dysfunction, delayed liberation from mechanical ventilation, and increased mortality. Despite appropriate provision of IVF, adverse drug effects such as electrolyte abnormalities and acid-base disturbances may occur. The management of volume status in critically ill patients is both dynamic and tenuous, a process that requires frequent monitoring and high clinical acumen. Because patient-specific considerations for fluid therapy evolve across the continuum of critical illness, a standard approach to the assessment of fluid needs and prescription of IVF therapy is necessary. We propose the principle of "fluid stewardship," guided by 4 rights of medication safety: right patient, right drug, right route, and right dose. The successful implementation of fluid stewardship will aid pharmacists in making decisions regarding IVF therapy to optimize hemodynamic management and improve patient outcomes. Additionally, we highlight several areas of focus for future research, guided by the 4 rights construct of fluid stewardship.
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Affiliation(s)
- W Anthony Hawkins
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA, USA.,Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Albany, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | - John R Carr
- Department of Pharmacy, St Joseph's/Candler Health System, Savannah, GA, USA
| | - Christopher M Bland
- Department of Pharmacy, St Joseph's/Candler Health System, Savannah, GA, USA.,Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, GA, USA
| | - Trisha N Branan
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
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29
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Walter JM, Kruser JM, Reyfman PA, Sporn PHS. Postextubation High-Flow Nasal Cannula Oxygen, Randomized Trial of an ICU Quality Improvement Intervention, and Midodrine during Recovery from Septic Shock. Am J Respir Crit Care Med 2019; 195:682-684. [PMID: 27911582 DOI: 10.1164/rccm.201607-1394rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- James M Walter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jacqueline M Kruser
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul A Reyfman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Peter H S Sporn
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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30
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Hammond DA, Smith MN, Peksa GD, Trivedi AP, Balk RA, Menich BE. Midodrine as an Adjuvant to Intravenous Vasopressor Agents in Adults With Resolving Shock: Systematic Review and Meta-Analysis. J Intensive Care Med 2019; 35:1209-1215. [PMID: 31030630 DOI: 10.1177/0885066619843279] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the effects of midodrine in addition to intravenous vasopressor therapy on outcomes in adults recovering from shock. MATERIALS AND METHODS PubMed, Scopus, Clinicaltrials.gov, and published abstracts were searched from inception to November 2018 for studies comparing outcomes in shock after midodrine initiation versus no midodrine. RESULTS Three studies with 2533 patients were included. Patients in whom midodrine was added to intravenous vasopressor therapy compared to intravenous vasopressor therapy alone experienced similar intensive care unit (ICU; mean difference [MD]: 1.38 days, 95% confidence interval [CI]: -3.48 to 6.23, I2 = 93%) and hospital lengths of stay (MD: 4.37 days, 95% CI: -3.45 to 12.19, I2 = 93%) and intravenous vasopressor duration after midodrine initiation (MD: 7.28 days, 95% CI: -0.86 to 15.41, I2 = 97%). Mortality was similar between groups (odds ratio: 0.74, 95% CI: 0.44-1.27, I2 = 65%). Qualitative assessment of reporting biases revealed minimal location bias, moderate selective outcome reporting bias, no selective analysis reporting bias, and no conflict of interest bias. CONCLUSIONS Midodrine had no effect on ICU or hospital length of stay. These results were highly susceptible to the study heterogeneity and availability. Future investigation into standardized initiation of midodrine at an adequate dosage with an expedited titration strategy is needed in order to assess the utility of this strategy in shock management.
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Affiliation(s)
- Drayton A Hammond
- Department of Pharmacy, 2468Rush University Medical Center, Chicago, IL, USA
| | - Melanie N Smith
- Department of Pharmacy, 2345 Medical University of South Carolina, Charleston, SC, USA
| | - Gary D Peksa
- Department of Pharmacy, 2468Rush University Medical Center, Chicago, IL, USA
| | - Abhaya P Trivedi
- Division of Pulmonary, Critical Care, and Sleep Medicine, 2345Rush University Medical Center, Chicago, IL, USA
| | - Robert A Balk
- Division of Pulmonary, Critical Care, and Sleep Medicine, 2345Rush University Medical Center, Chicago, IL, USA
| | - Bryan E Menich
- Department of Pharmacy, 2468Rush University Medical Center, Chicago, IL, USA
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31
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Buckley MS, Barletta JF, Smithburger PL, Radosevich JJ, Kane-Gill SL. Catecholamine Vasopressor Support Sparing Strategies in Vasodilatory Shock. Pharmacotherapy 2019; 39:382-398. [PMID: 30506565 DOI: 10.1002/phar.2199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Shock syndromes are associated with unacceptably high rates of mortality in critically ill patients despite advances in therapeutic options. Vasodilatory shock is the most common type encountered in the intensive care unit. It is manifested by cardiovascular failure, peripheral vasodilatation, and arterial hypotension leading to tissue hypoperfusion and organ failure. Hemodynamic support is typically initiated with fluid resuscitation strategies and administration of adrenergic vasopressor agents in nonresponsive patients to restore arterial pressure with subsequent adequate organ reperfusion. Unfortunately, high catecholamine dosing requirements may be necessary to achieve targeted hemodynamic goals that may increase the risk of vasopressor-induced adverse events. The purpose of this article is to review the clinical efficacy and safety data and potential role in therapy for catecholamine-sparing agents in vasodilatory shock. Adjunctive therapeutic options to reduce vasoactive support requirements without compromising arterial pressure include arginine vasopressin and analogs, corticosteroids, midodrine, methylene blue, and angiotensin II. Although concomitant vasopressin and corticosteroids have a more defined role in evidence-based guidelines for managing shock, clinicians may consider other potential catecholamine-sparing agents.
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Affiliation(s)
- Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy - Glendale, Midwestern University, Glendale, Arizona
| | - Pamela L Smithburger
- Department of Pharmacy Practice, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - John J Radosevich
- Department of Pharmacy, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sandra L Kane-Gill
- Department of Pharmacy Practice, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
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32
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Whitson MR, Mo E, Healy L, Narasimhan M, Koenig S, Mayo PH. Response. Chest 2018; 149:1583-4. [PMID: 27287582 DOI: 10.1016/j.chest.2016.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 11/25/2022] Open
Affiliation(s)
- Micah R Whitson
- Department of Emergency/Internal/Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY.
| | - Edwin Mo
- Department of Emergency/Internal/Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY
| | - Lauren Healy
- Department of Pharmacy, North Shore-LIJ Health System, New Hyde Park, NY
| | - Mangala Narasimhan
- Department of Pulmonary and Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY
| | - Seth Koenig
- Department of Pulmonary and Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY
| | - Paul H Mayo
- Department of Pulmonary and Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY
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33
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Hammond DA, Smith MN, Meena N. Considerations on Midodrine Use in Resolving Septic Shock. Chest 2018; 149:1582-3. [PMID: 27287581 DOI: 10.1016/j.chest.2016.03.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 03/15/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- Drayton Adam Hammond
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR.
| | - Melanie N Smith
- Department of Pharmacy, University of Florida Health, Jacksonville, FL
| | - Nikhil Meena
- Pulmonary and Critical Care, University of Arkansas for Medical Sciences and the Central Arkansas Veterans Hospital System, and Department of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
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34
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35
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Hammond DA, McCain K, Painter JT, Clem OA, Cullen J, Brotherton AL, Chopra D, Meena N. Discontinuation of Vasopressin Before Norepinephrine in the Recovery Phase of Septic Shock. J Intensive Care Med 2017; 34:805-810. [PMID: 28618919 DOI: 10.1177/0885066617714209] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Guidance for the discontinuation of vasopressors in the recovery phase of septic shock is limited. Norepinephrine is more easily titrated; however, septic shock is a vasopressin deficient state, which exogenous vasopressin endeavors to resolve. Discontinuation of vasopressin before norepinephrine may result in clinically significant hypotension. METHODS This retrospective, cohort study compared discontinuation of norepinephrine and vasopressin in medically, critically ill patients in the recovery phase of septic shock from May 2014 to June 2016. Difference in clinically significant hypotension after norepinephrine or vasopressin discontinuation was evaluated with χ2 test. Linear regression was performed, examining the effect of agent discontinuation on clinically significant hypotension. Baseline variables were examined for a bivariate relationship with clinically significant hypotension; those with P < .2 were included in the model. RESULTS Vasopressin was discontinued first or last in 62 and 92 patients, respectively. Sequential Organ Failure Assessment scores at 72 hours (7.9 vs 7.6, P = .679) were similar. In unadjusted analysis, when vasopressin was discontinued first, more clinically significant hypotension developed (10.9% vs 67.8%, P < .001). There was no difference in intensive care unit (174 vs 216 hours, P = .178) or hospital duration (470 vs 473 hours, P = .977). In adjusted analyses, discontinuing vasopressin first was associated with increased clinically significant hypotension (odds ratio [OR]: 13.837, 95% confidence interval [CI]: 3.403-56.250, P < .001) but not in-hospital (OR: 0.659, 95% CI: 0.204-2.137, P = .488) or 28-day mortality (OR: 0.215, 95% CI: 0.037-1.246, P = .086). CONCLUSION Adult patients receiving norepinephrine and vasopressin in the resolving phase of septic shock may be less likely to develop clinically significant hypotension if vasopressin is the final vasopressor discontinued.
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Affiliation(s)
- Drayton A Hammond
- 1 University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA.,2 University of Arkansas for Medical Sciences Medical Center, Little Rock, AR, USA
| | - Kelsey McCain
- 1 University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA.,2 University of Arkansas for Medical Sciences Medical Center, Little Rock, AR, USA
| | - Jacob T Painter
- 1 University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Oktawia A Clem
- 1 University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Julia Cullen
- 1 University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | | | - Divyan Chopra
- 1 University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Nikhil Meena
- 2 University of Arkansas for Medical Sciences Medical Center, Little Rock, AR, USA.,4 University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, USA
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36
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Anstey MH, Wibrow B, Thevathasan T, Roberts B, Chhangani K, Ng PY, Levine A, DiBiasio A, Sarge T, Eikermann M. Midodrine as adjunctive support for treatment of refractory hypotension in the intensive care unit: a multicenter, randomized, placebo controlled trial (the MIDAS trial). BMC Anesthesiol 2017; 17:47. [PMID: 28327122 PMCID: PMC5361788 DOI: 10.1186/s12871-017-0339-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients admitted to intensive care units (ICU) are often treated with intravenous (IV) vasopressors. Persistent hypotension and dependence on IV vasopressors in otherwise resuscitated patients lead to delay in discharge from ICU. Midodrine is an oral alpha-1 adrenergic agonist approved for treatment of symptomatic orthostatic hypotension. This trial aims to evaluate whether oral administration of midodrine is an effective adjunct to standard therapy to reduce the duration of IV vasopressor treatment, and allow earlier discharge from ICU and hospital. METHODS The MIDAS trial is an international, multicenter, randomized, double-blind, placebo-controlled clinical trial being conducted in the USA and Australia. We are targeting 120 patients. Adult patients admitted to the ICU who are resuscitated and otherwise stable on low dose IV vasopressors for at least 24 h will be considered for recruitment. Participants will be randomized to receive midodrine (20 mg) or placebo three times a day, in addition to standard care. The primary outcome is time (hours) from initiation of midodrine or placebo to discontinuation of IV vasopressors. Secondary outcomes include time (hours) from ICU admission to discharge readiness, ICU length of stay (LOS) (days), hospital LOS (days), rates of ICU readmission, and rates of adverse events related to midodrine administration. DISCUSSION Midodrine is approved by the Food and Drug Administration (FDA) for the treatment of symptomatic orthostatic hypotension. In August 2010, FDA proposed to withdraw approval of midodrine because of lack of studies that verify the clinical benefit of the drug. We obtained Investigational New Drug (IND 113,330) approval to study its effects in critically ill patients who require IV vasopressors but are otherwise ready for discharge from the ICU. A pilot observational study in a cohort of surgical ICU patients showed that the rate of decline in vasopressor requirements increased after initiation of midodrine treatment. We hypothesize that midodrine administration is effective to wean IV vasopressors and shorten ICU and hospital LOS. This trial may have significant implications on lowering costs of hospital care and obtaining FDA approval for new indications for midodrine. TRIAL REGISTRATION This study has been registered at clinicaltrials.gov on 02/09/2012 (NCT01531959).
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Affiliation(s)
- Matthew H Anstey
- Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Bradley Wibrow
- Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Tharusan Thevathasan
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | | | - Khushi Chhangani
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Pauline Yeung Ng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - Alexander Levine
- Department of Pharmacy Practice and Administration, University of Saint Joseph, Hartford, CT, USA
| | - Alan DiBiasio
- Department of Pharmacy, Massachusetts General Hospital, Boston, USA
| | - Todd Sarge
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, USA
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA. .,Universitaet Duisburg Essen, Klinik fuer Anaesthesiologie und Intensivmedizin, Essen, Germany.
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Zundel MT, Boettcher BT, Feih JT, Gaglianello N, Pagel PS. Use of Oral Droxidopa to Improve Arterial Pressure and Reduce Vasoactive Drug Requirements During Persistent Vasoplegic Syndrome After Cardiac Transplantation. J Cardiothorac Vasc Anesth 2016; 30:1624-1626. [DOI: 10.1053/j.jvca.2015.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Indexed: 11/11/2022]
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Methylene blue, midodrine, and pseudoephedrine: a review of alternative agents for refractory hypotension in the intensive care unit. Crit Care Nurs Q 2016; 38:345-58. [PMID: 26335214 DOI: 10.1097/cnq.0000000000000086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hypotensive episodes are common among patients in the intensive care unit and can lead to multiorgan failure if uncontrolled. Fluid administration and continuous infusion of vasoactive agents are frequently used for management of hypotension; however, both therapies may be associated with adverse effects including pulmonary edema and tissue necrosis. In addition, availability of these first-line agents has been impacted by the increasing occurrence of drug shortages. Methylene blue, pseudoephedrine, and midodrine have been considered potential alternatives to standard therapy. These agents may not only be used when first-line agents are unavailable due to shortages, but they may also aid in reducing the cumulative dose of other vasoactive agents used. The purpose of this review was to discuss strategies for the safe and effective use of methylene blue, pseudoephedrine, and midodrine for the treatment of hypotension in the critically ill.
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Poveromo LB, Michalets EL, Sutherland SE. Midodrine for the weaning of vasopressor infusions. J Clin Pharm Ther 2016; 41:260-5. [PMID: 26945564 DOI: 10.1111/jcpt.12375] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 02/10/2016] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Midodrine, an orally available α1-agonist indicated for the treatment of orthostatic hypotension, has been used at our institution as an adjunctive treatment to provide haemodynamic support to facilitate intravenous (IV) vasopressor weaning. Limited published data exist for this off-label use; thus, the objective of this study was to evaluate outcomes in patients who received midodrine for IV vasopressor weaning compared to control patients. METHODS This retrospective comparison included adult ICU patients admitted to our institution from January 2007 to March 2012. The primary outcome was the time to IV vasopressor discontinuation after midodrine initiation. Secondary outcomes included a comparison between midodrine and control patients of the time from IV vasopressor discontinuation to ICU discharge, hospital and ICU length of stay (LOS), and the number of ICU readmissions. RESULTS AND DISCUSSION The analysis included 188 patients (94 midodrine and 94 control). Patients discontinued IV vasopressors a median of 1·2 days (IQR 0·5-2·8) after midodrine initiation. ICU discharge occurred sooner after IV vasopressor discontinuation (0·8 vs. 1·5 days, P = 0·01), and 96% of patients remained off IV vasopressors after midodrine treatment. Hospital LOS was longer in midodrine patients (P < 0·01), but there were no differences in ICU LOS or readmissions. Adverse event rates after midodrine use were consistent with those observed in other studies. WHAT IS NEW AND CONCLUSION Midodrine may serve as a useful adjunct to wean IV vasopressors in difficult-to-wean patients. Further studies are needed to assess the efficacy and safety of midodrine for this indication.
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Affiliation(s)
- L B Poveromo
- Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - E L Michalets
- Department of Pharmacy, Mission Health System, Eshelman School of Pharmacy, University of North Carolina, Asheville, NC, USA
| | - S E Sutherland
- Greenville Health System Care Coordination Institute, Greenville, SC, USA
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Whitson MR, Mo E, Nabi T, Healy L, Koenig S, Narasimhan M, Mayo PH. Feasibility, Utility, and Safety of Midodrine During Recovery Phase From Septic Shock. Chest 2016; 149:1380-3. [PMID: 26953217 DOI: 10.1016/j.chest.2016.02.657] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/06/2016] [Accepted: 02/18/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND We describe the feasibility, utility, and safety of oral midodrine to replace IV vasopressors during recovery from septic shock. METHODS This was a retrospective study performed in a medical ICU. All study subjects had a diagnosis of septic shock requiring at least 24 hours of IV vasopressors and demonstrated clinical stability with stable or decreasing doses of IV vasopressors. The two groups compared were those who received IV vasopressors only and those who received IV vasopressors with adjunctive midodrine. RESULTS Of the 275 study patients, 140 received an IV vasopressor only and 135 received midodrine in addition to an IV vasopressor. There was no difference between the groups' demographics (age, sex, Acute Physiology and Chronic Health Evaluation 4 score). Mean IV vasopressor duration was 3.8 days in the IV vasopressor only group and 2.9 days in the IV vasopressor with midodrine group (P < .001). An IV vasopressor was reinstituted after discontinuation in 21 of 140 (15%) patients in the IV vasopressor only group and in 7 of 135 (5.2%) patients in the IV vasopressor with midodrine group (P = .007). ICU length of stay was 9.4 days in the IV vasopressor only group and 7.5 days in the IV vasopressor with midodrine group (P = .017). There were no complications associated with midodrine use except transient bradycardia in one patient, which resolved upon discontinuation of midodrine. CONCLUSIONS Midodrine may reduce the duration of IV vasopressors during recovery phase from septic shock and may be associated with a reduction in length of stay in the ICU.
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Affiliation(s)
- Micah R Whitson
- Department of Emergency/Internal/Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY.
| | - Edwin Mo
- Department of Emergency/Internal/Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY
| | - Tasnima Nabi
- Department of Pharmacy, North Shore-LIJ Health System, New Hyde Park, NY
| | - Lauren Healy
- Department of Pharmacy, North Shore-LIJ Health System, New Hyde Park, NY
| | - Seth Koenig
- Department of Pulmonary and Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY
| | - Mangala Narasimhan
- Department of Pulmonary and Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY
| | - Paul H Mayo
- Department of Pulmonary and Critical Care Medicine, North Shore-LIJ Health System, New Hyde Park, NY
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