We appreciate the interest of Drs Sagar and Vijhani regarding our study, which reported our experience with midodrine use in patients recovering from septic shock. In answer to their questions:
Median ICU length of stay (LOS) was 8 days in the IV vasopressor-only group and 4 days in the IV vasopressor with midodrine group (P = .017). ICU LOS was calculated using midnight bed occupancy days as recommended by Marik and Hedman (Table 1).
Median Acute Physiology and Chronic Health Evaluation (APACHE IV) scores were 83 in the IV vasopressor-only group and 77.5 in the IV vasopressor with midodrine group (P = .55) (Table 2).
Regarding the 18 patients discharged on midodrine, disposition and dosing were varied. Seven patients were discharged to hospice care, and one patient was transferred to another facility. Four patients were discharged home taking midodrine during hemodialysis only, which is a common safe practice. Six patients were discharged to rehabilitation centers, and the highest dosage at discharge was 10 mg tid. As these patients were discharged after transfer to the primary team from the ICU, we cannot comment on the treatment or discharge decisions regarding midodrine use. We also cannot comment on the outpatient duration, down titration, or outcomes of midodrine therapy in these patients. For a hospital inpatient, we recommend decremental titration of midodrine by 5 to 10 mg per dose on a daily basis until discontinuation while monitoring for hypotension or symptoms. If hypotension occurs, the prior stable midodrine dose should be reinstated. We do not recommend the routine use of daily midodrine for outpatients during recovery from septic shock.