(1651) Retrospective Review of Midodrine Use in Shock Patients in the Intensive Care Unit

Introduction: The purpose of this study was to evaluate the efficacy of midodrine for the treatment of vasopressor dependent shock in the intensive care unit (ICU). Midodrine has been used off-label to treat hypotension in the ICU for patients diagnosed with shock. Currently, there is conflicting evidence on the safety and efficacy of midodrine for this indication.

Methods: A single-center, retrospective review of patients admitted to RWJBarnabas Health Community Medical Center ICU, which included the medical intensive care unit (MICU), surgical intensive care unit (SICU), and cardiac care unit (CCU), who received vasopressor(s) with a diagnosis of shock from May 1, 2023 to May 1, 2024 were identified. Patients were assigned to one of two groups; received midodrine or did not receive midodrine. The primary outcome was vasopressor free days at 30 days from initiation of vasopressor(s). Secondary outcomes included ICU length of stay, hospital length of stay, rate of vasopressor reinstitution, and length of time on vasopressor(s) prior to midodrine transition. The safety outcome measured was the occurrence of bradycardia, defined as a heart rate less than 60 beats per minute. Patients were excluded if they used midodrine as a home medication, use of midodrine for any indication other than shock, and vasopressor use less than 24 hours.

Results: A total of 324 patients were included in the analysis, 124 patients who received midodrine, and 200 patients who did not receive midodrine. Patients who received midodrine had an average of 18.5 vasopressor free days, compared to 12.8 days for patients who did not receive midodrine (p < 0.01). Patients who received midodrine, on average, had a longer duration of ICU stay (7.6 days vs. 5 days, p< 0.01) and hospital stay (19.9 days vs. 10.6 days, p < 0.01). The average duration of time on vasopressors prior to midodrine initiation was 55.1 hours. Bradycardia occurred more often in the midodrine group (55% vs. 42%, p=0.02).

Conclusions: The results of this trial show that initiation of midodrine in patients receiving vasopressors may reduce vasopressor free days but was associated with an increase in both ICU and hospital length of stay. Bradycardia did occur at a higher rate in those who received midodrine, so caution must be used prior to initiation.