Wait, What? Oral Midodrine Instead of Pressors for Septic Shock?

ABSTRACT

Background: Coincident with capacity strains on our institution's intensive care units (ICUs) during the Covid-19 pandemic, we perceived an increase in the use of oral Midridone (MID) administration for blood pressure (BP) support in septic shock patients to avoid intravenous (IV)-vasoactive medications and ICU admission. Little is known about the efficacy of MID in this patient cohort. The goal of this study was to evaluate the clinical outcomes associated with use of MID to augment blood pressure support in ED patients with septic shock. Method(s) For this single center retrospective review of patients requiring pressor support after sepsis bundle activation, we assessed frequency of IV versus PO vasoactive medication administration both within the ED and after admission on patient outcomes including length of ED stay, admission level of care, discharge disposition, and mortality. Result(s) Of 6293 ED sepsis bundle activations from January 1st, 2019 to April 20th, 2022, 327 (5.2%) of these patients were in shock requiring vasopressors in the ED. Of these patients, 249 received IV vasopressors (IVP), most frequently norepinephrine, but 62 received only MID while 16 patients were given both IVP and MID. The cumulative in-hospital mortality rate (MR) for administration of any of these medications in the ED was 40%. For those who received IVP only, MR was 47%;for MID only it was 14.5%;and for those who received both MR was 31.3%. EDLOS was shortest (6.92 hours) for patients receiving IVP only but increased to 11.7 hours for IVP + MID and 18.9 hours for MID. ICU admission rates were greatest (67.5%) for IVP only patients which decreased to 41.2% for MID + IVP and only 1.6% for MID. Hospital LOS was 7.81 days for IVP only, 12.75 days for MID + IVP, and 6.78 days for MID. Additionally, there were 430 patients who were initially stable in the ED but subsequently decompensated requiring initiation of vasopressive medications after hospital admission with a 40% overall MR for these patients. 210 patients were given IVP (32% MR), 118 requiring only MID (24% MR), while 102 received both (37% MR). Conclusion(s) In this cohort of sepsis patients requiring blood pressure support, patients who received oral Midodrine in place of IVP had longer ED LOS, lower ICU admission rates, and lower mortality rate then patients who received IVP. However, with a less acute ESI score (average 2.1 for MID only vs 1.7 for IVP only) this cohort who composed 19% of septic shock patients presenting to the ED seemed to be considered "less sick" upon arrival. Future prospective research is required to explore the safety and efficacy of oral midodrine in the ED sepsis population requiring blood pressure support. No, authors do not have interests to disclose Copyright © 2022