Evidence based treatment of “the dwindles” (persistent mild hypotension)

Persistent hypotension requiring vasopressors is a common situation in the ICU. Doing “nothing” is acceptable but entails exposing patients to increased risk of infections and delays their recovery. Four strategies are available, three of which are supported by evidence: choose a MAP goal of >60, wean NE before vasopressin, and consider adding corticosteroids. Ongoing studies may support a role for oral vasopressors, but the current data is lacking.

Is the Juice Worth the Squeeze? Using Midodrine

If midodrine is used for vasopressor weaning, it is important to have plans in place for tapering and discontinuation at transitions of care.

Intradialytic hypotension: Is midodrine beneficial in symptomatic hemodialysis patients?

Our results suggest that the administration of a single dose of midodrine before hemodialysis is an effective therapy for intradialytic hypotension. A prospective trial with adequate patient numbers and long-term follow-up would be useful to evaluate this drug's efficacy and safety profile in patients with ESRD.

Meet Midodrine, an Alpha Agonist: Case Study

Midodrine is an alpha agonist and if we think about this mechanism of action, it directly opposes the action of alpha blockers used more so for the acute (and sometimes long term) management of urinary retention usually due to BPH in males.

Midodrine and albumin as a possible “winning pair” in managing paracentesis-induced circulatory dysfunction: a clinical case report

Our clinical case wants to show how not all PICDs are secondary to hepatic dysfunctions with Midodrine playing a possible therapeutic role by counteracting the pathophysiological mechanism in a rapid and non-invasive way, representing a valid therapeutic option in adjunction to albumin.

Midodrine for the Prevention of Vasovagal Syncope

Vasovagal syncope and orthostatic hypotension have a lot in common. Both result in vasodilation and pooling of blood in the periphery, reducing cerebral blood flow. Midodrine is a sympathomimetic that stimulates the alpha-adrenergic nervous system. It increases peripheral vascular tone, pushing more blood to the brain.

Midodrine Is Worth a Trial in People With Frequent Episodes of Vasovagal Syncope

Midodrine is a vasoconstrictor used to prevent orthostatic hypotension and may reduce the likelihood of recurrence of vasovagal syncope in patients with frequent episodes. It seems to work completely or not at all;

Midodrine Most Effective Pharmacological Intervention for Vasovagal Syncope

This analysis is limited by the small sample sizes and the lack of direct head-to-head comparisons of pharmacological interventions.

Midodrine: A New Drug for Orthostatic Hypotension

The drug may be useful in a small number of patients with disabling orthostatic hypotension who are unresponsive to other maneuvers.

Oral vasopressor to accelerate liberation from the ICU

Midodrine is an oral agent which functions as an alpha-1 agonist. It has been used in a variety of situations including autonomic dysfunction, hepatorenal syndrome, and dialysis-induced hypotension. Over the past few years there has been increasing interest in using midodrine to facilitate weaning off vasopressors.

The MIDAS Trial – Midodrine vs Placebo for Pressor Discontinuation

Midodrine did not reduce time to discontinuation of IV vasopressors in critically ill patients with persistent hypotension. The lack of effectiveness combined with higher rate of bradycardia does not support the routine use of midodrine to accelerate liberation from IV vasopressors in the ICU.

The Use of Midodrine for Persistent Vasoplegia and Inability to Wean IV Vasopressors?

Midodrine may help restore the vascular tone by stimulating the alpha-1 receptors on the vascular smooth muscle cells, which are relatively spared from desensitization compared to the beta receptors. Moreover, midodrine may have synergistic effects with other vasopressors by enhancing their vasoconstrictive action. For example, midodrine may increase the sensitivity of the vascular smooth muscle cells to norepinephrine by upregulating the expression of alpha-1 receptors. Midodrine may also augment the release of endogenous norepinephrine from sympathetic nerve terminals by blocking its reuptake.

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

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.