0
Correspondence |

Response FREE TO VIEW

Micah R. Whitson, MD; Edwin Mo, MD; Lauren Healy, PharmD; Mangala Narasimhan, DO; Seth Koenig, MD; Paul H. Mayo, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

CORRESPONDENCE TO: Micah Riley Whitson, MD, North Shore–LIJ Health System, Critical Care Medicine, 27005 76th Ave, New Hyde Park, NY 11040


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(6):1583-1584. doi:10.1016/j.chest.2016.03.058
Text Size: A A A
Published online

We appreciate the correspondence of Drs Hammond, Smith, and Meena and their interest in our study examining the use of midodrine during resolution of septic shock. In response to their comments regarding the findings of our study compared with a recent retrospective study by Poveromo et al, we agree that the populations in the two studies were markedly different. In the study by Poveromo et al, < 15% of patients received a diagnosis of septic shock, and “providers elected to use midodrine in a patient population inherently different from those who did not receive midodrine.” In their study, midodrine was used predominantly in patients who had already failed IV vasopressor weaning. In addition, the midodrine doses observed in our study were twice those observed by Poveromo et al. Midodrine has been shown to reduce the dosage of IV vasopressors, and our findings of a shortened ICU length of stay may be secondary to our unique patient population experiencing vasoplegia in septic shock and the early institution of higher doses of midodrine prior to failed or difficult weaning of IV vasopressors.

We had no written protocol for patient selection or administration of midodrine, but in accordance with our usual practice, midodrine was not given to patients taking multiple vasopressors, including vasopressin in combination with norepinephrine or phenylephrine. A minority of patients in our study received corticosteroids (26% and 28% in each group), and it is our practice to rapidly reduce steroid doses after IV vasopressor discontinuation simultaneous with a reduction in midodrine dosing.

In our institution, midodrine is routinely initiated at 20 mg every 8 h and increased by 10 mg with each subsequent dose to a maximum of 40 mg every 8 h. Most patients receiving midodrine are discharged from the ICU once IV vasopressors have been discontinued for 24 h, and the dose of midodrine is then decreased by the primary team assuming care. We recommend the dose be decreased by 5 to 10 mg daily until discontinuation, but we cannot comment on the routine decremental titration of midodrine outside the ICU.

We agree that randomized, placebo-controlled studies are needed to determine efficacy and the most appropriate patient selection and dosing protocols for midodrine use in patients with hypotension.

References

Whitson M.R. .Mo E. .Nabi T. .et al Feasibility, utility, and safety of midodrine during recovery phase from septic shock. Chest. 2016;149:1380-1383 [PubMed]journal
 
Poveromo LB, Michalets EL, Sutherland SE. Midodrine for the weaning of vasopressor infusions [published online ahead of print March 4, 2016].J Clin Pharm Ther.http://dx.doi.org/10.1111/jcpt.12375.
 
Levine A.R. .Meyer M.J. .Bittner E.A. .et al Oral midodrine treatment accelerates the liberation of intensive care unit patients from intravenous vasopressor infusions. J Crit Care. 2013;28:756-762 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Whitson M.R. .Mo E. .Nabi T. .et al Feasibility, utility, and safety of midodrine during recovery phase from septic shock. Chest. 2016;149:1380-1383 [PubMed]journal
 
Poveromo LB, Michalets EL, Sutherland SE. Midodrine for the weaning of vasopressor infusions [published online ahead of print March 4, 2016].J Clin Pharm Ther.http://dx.doi.org/10.1111/jcpt.12375.
 
Levine A.R. .Meyer M.J. .Bittner E.A. .et al Oral midodrine treatment accelerates the liberation of intensive care unit patients from intravenous vasopressor infusions. J Crit Care. 2013;28:756-762 [PubMed]journal. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543