(1774) Impact of Pseudoephedrine and/or Midodrine on Neurogenic Shock Following Acute Spinal Cord Injury

Tuesday, February 25, 2025

11:15am – 12:15pm Eastern Time

Location: Connections Central - RST 03

First Author(s)

CW

Chris Wood, BCCCP, PharmD, FCCP, FCCM (he/him/his)

University of Tennessee Health Science Center
University of Tennessee Health Science Center College of Pharmacy
Memphis, Tennessee, United States

Co-Author(s)

KC

Kaitlin Cauthen, Pharm.D.

Critical care pharmacy resident
University of Tennessee, United States
JF

Julie Farrar, PharmD, BCCCP

University of Tennessee College of Pharmacy
Memphis, Tennessee, USA
CS

Caitlin Sayyid, M.D.

Trauma Fellow
University of Tennessee Health Science Center, United States
RB

Reid Bartholomew, M.D.

Trauma Fellow
University of Tennessee, United States
SB

Saskya Byerly, MD, MS

Assistant Professor of Trauma/Surgical Critical Care
n/a
Memphis, Tennessee, United States
DF

Dina M. Filiberto, MD, MS

Associate Professor of Trauma/Surgical Critical Care, Fellowship Program Director
University of Tennessee Health Science Center
Memphis, Tennessee, United States

Co-Author(s)

Joseph M. Swanson, PharmD, FCCP, FCCM (he/him/his)

Pharmacist
University of Tennessee Health Science Center College of Pharmacy
Bartlett, Tennessee, United States

Introduction: Neurogenic shock is a potentially serious complication of spinal cord injury (SCI). There are very limited data on oral/enteral therapy beyond IV vasopressors. This study evaluated the efficacy and safety of pseudoephedrine (PSE) and midodrine (MID), both alone and in combination, for neurogenic shock. It was hypothesized that PSE and/or MID would be effective for hypotension and PSE would also be effective for bradycardia based on their pharmacology.

Methods: This retrospective cohort study was conducted at a large academic hospital and Level 1 Trauma Center. Patients ≥18 years, admitted between 07/2019 to 08/2023 with acute SCI, and received ≥1 day of PSE and/or MID were included. Patients were excluded if pregnant, breastfeeding, or experienced shock unrelated to SCI. Patients were divided into three study groups: PSE only, PSE+MID, and MID only.
The primary outcome was incidence of hypotension (MAP < 65 mmHg) and bradycardia (HR < 60 bpm) within 7 days of PSE and/or MID initiation. Secondary outcomes included duration of IV vasopressors after PSE and/or MID, and the potential adverse events of hypertension (MAP >95 mmHg) or tachycardia (HR >100 bpm) within the study period.

Results: Of 92 patients included, 74 received PSE, 9 received PSE+MID, and 9 received MID. The combined PSE groups (PSE and PSE+MID) were more severly injured (median injury severity score 26 vs 17, p< 0.05) and more instances of complete SCI (47% vs 11%, p< 0.05) than the MID group. Hypotension was statistically similar between the three groups at baseline as well as day 7. Bradycardia was more common in the PSE group at baseline compared to the PSE+MID or MID groups (49% vs 0% vs 22%, p< 0.05). However, bradycardia resolved in the PSE group and was similar to the other groups by day 7 (18% vs 33%, 20%, p=NS). IV vasopressor use (69% vs. 67%, vs 89%, p>0.05), duration (2.2 vs. 4.8 vs. 2.3 days, p>0.05), and reinitiation (15% vs 33 % vs 22%, p>0.05) were not different between groups. There was no difference in hypertension or tachycardia between groups.

Conclusions: In neurogenic shock after acute SCI, PSE and/or MID were associated with resolution of hypotension. PSE was also associated with resolution of bradycardia.