Effect of midodrine on length of stay in adult patients with septic shock

Introduction: Midodrine is increasingly used in critically ill patients with septic shock to facilitate weaning intravenous (IV) vasopressors and discharge from the intensive care unit. Despite a trend of increasing use, current data demonstrate mixed efficacy in liberation from vasopressors or reduction in length of stay (LOS). Our study aimed to evaluate real-world data on the effect of midodrine on LOS in patients admitted for septic shock. Methods: Our analysis used de-identified data from the Trisus Medication Compare platform (The Craneware Group, Deerfield Beach, FL) to identify adults with septic shock (ICD-10 code R65.21) and a dispensation for any vasopressor between 1/1/2019-3/31/2022. The primary objective was to compare average in-hospital LOS in patients receiving midodrine versus not. Subgroup analyses were performed in patients requiring invasive mechanical ventilation (IMV), renal replacement therapy (RRT), and two or more vasopressors. Secondary outcomes included 30-day all-cause readmission, bradycardia, and catheter-related bloodstream infection. Continuous and discrete outcomes were assessed using Kruskal-Wallis and Chi-square tests, respectively. Results: A total of 68,935 encounters were captured (midodrine, n=9,053; no midodrine, n=59,882). Diabetes mellitus, liver disease, chronic kidney disease, and heart failure were more common in patients who received midodrine, while hypertension was more common in those who didn’t. About 65.1% of patients required IMV. Patients receiving midodrine had higher use of RRT, two or more vasopressors, and IV hydrocortisone. The average in-hospital LOS was longer in patients receiving midodrine (22.6±25.6 vs 14.5±18.7 days), consistent across subgroup analyses. In addition, 30-day all-cause readmission was higher in those with a dispensation for midodrine (13.8%) vs those without (10.1%, p< 0.01). Surprisingly, more patients in the no midodrine group had bradycardia (3.0% vs 2.5%, p< 0.01), while more patients receiving midodrine developed catheter-related bloodstream infections (3.0% vs < 0.1%, p< 0.01). Conclusions: Use of midodrine in adults with septic shock was associated with longer hospital LOS and a higher 30-day readmission rate.