Midodrine for the Prevention of Escalation of Care in Septic Patients

Introduction: Midodrine acts as a direct vasoconstrictor via alpha-1 agonism. Recently, midodrine has been used to facilitate vasopressor discontinuation. Limited data regarding its impact on prevention of escalation of care (EOC) in septic patients. Midodrine has the potential to provide blood pressure support in septic patients who are unable to maintain an adequate MAP despite fluid resuscitation. This study aimed to identify factors in septic patients on midodrine that prevented EOC.


Methods: The study was an IRB approved, single center, retrospective cohort study of adult non-ICU septic patients who received midodrine for blood pressure support between January 1, 2023 and November 1, 2024. Patients were excluded if on midodrine at home or if patient/family did not want EOC. The primary outcome was EOC defined as a patient transferred to an area with increased care abilities. Secondary outcomes included time to EOC, ICU admission, time to ICU admission, hospital length of stay, mortality, and midodrine on hospital discharge.


Results: A total of 585 patients were screened for inclusion with 50 patients included in the analysis. The primary outcome, EOC, occurred in 11 (22%) patients. Patient characteristics were comparable between the two groups, with the majority of patients were female with a similar age, comorbid conditions and midodrine dose. The escalation group was less likely to receive a fluid bolus (63.6% vs 79.5%, p = 0.277). The median fluid volume was 25.6 ml/kg in the no escalation group vs 12.3 ml/kg in the escalation group. The secondary outcome, admission to ICU occurred in 63% of escalated patients. Median time to EOC and ICU was 1.4 days [IQR 21.2] and 2.5 days [IQR 23.5], respectively. Hospital LOS did not differ between the groups. Overall study mortality was greater than the institutional sepsis mortality rate (22% vs 14%). Non-escalated patient were more often discharged on midodrine.


Conclusions: There were no patient factors identified that contributed to escalation of care. Non-ICU septic patients who received midodrine for blood pressure support, were less likely to receive guideline directed fluid resuscitation, and had a higher mortality rate compared to overall study site sepsis mortality. Additional studies are needed to determine midodrine’s role in sepsis resuscitation.