Study Design Summary: Multicenter trial comparing 132 total patients who were on predefined low dose vasopressor support for at least 24 hours, randomized to receive oral midodrine or not with primary end point being time in hours to vasopressor discontinuation from randomization.
Notes: The study defined successful discontinuation of vasopressors as off pressors for 24 hours. The study was overall small in number (n=132) but they prespecificed a N of 120 to detect a 6 h difference. The groups were similar in terms of demographics, indication for ICU admission and baseline MAP.
Median time to discontinuation was 23.5 hours in midodrine group vs 22.5 hours in control group. ICU discharge readiness was the same at 5 days amongst the intervention and control group. The overall number of adverse events was reported as the same between the two groups, but a table of these events was not shown. They did, however, report that midodrine vs control group there was HTN episodes 7 vs 3, bradycardia episodes 5 vs 0, and a trial fibrillation episodes 3 vs 1; of these adverse events the only that reached statical significance was bradycardia with p=0.02.
Interestingly, there was significant decrease in time to vasopressor discontinuation in patients with epidural anesthesia receiving midodrine as compared to control group. Authors offer this explanation which I think is good, “First, the mechanism of hypotension during epidural analgesia and orthostatic hypotension, for which midodrine’s efficacy has been demonstrated in randomised trials [21, 22], is identical, namely neural vasoplegia resulting from dila- tion of both resistance and capacitance vessels in the anaesthetised area [where as it is a different cause of vasoplegia in conditions such as sepsis]. Second, it is possible that epidural analgesia may improve the absorption of oral medica- tions like midodrine. Epidural analgesia has been shown to facilitate recovery of gastrointestinal function.”
Study Conclusion: Midodrine did not reduce time to vasopressor discontinuation, there were increased rates of bradycardia in the midodrine group and thus these result do not support the routine use of midodrine in critically ill patients to accelerate liberation from intravenous vasopressor support in the ICU.
Fusion Beat Bottom Line Impression: Addition of oral midodrine did not improve time to IV vasopressor discontinuation and there were slightly more adverse events in the midodrine group leading to a Fusion Beat bottom line that midodrine should not be used to accelerate vasopressor discontinuation.
A Fusion Beat 