In patients with persistent borderline hypotension recovering from sepsis or critical illness, do you use midodrine to avoid escalating to higher levels of care?

Although midodrine is a medication that can be used to avoid vasopressors, I think it is much more important to give isotonic fluids when the patient would benefit from fluids. It is also very important to determine the etiology of hypotension. Is hypotension related to sepsis? Hypovolemia? Bleeding? PE? Adrenal insufficiency?

Once the underlying cause is found, it must be treated.

Giving midodrine is not a fix and can potentially mask hypotension for an underlying etiology, and can falsely reassure the treatment team.

I routinely consider it, but rarely use it. Midodrine must be renally dosed and not used with significant renal impairment, and also causes significant bradycardia. Therefore, most of the patients I would want to consider using it with don’t qualify. Most of my patients have underlying hypertension, and if they are borderline hypotensive, then they are quite sick. Also, most have AKI that is ongoing or recently recovered, and I have seen Midodrine worsen creatinine, especially with recent AKI. For the patients that do qualify, I find that Midodrine can help increase their MAP only by about 5 mmMg. This is enough for some people to keep them off pressors, but not for most. Despite the fairly low success rate, I do think it’s worth trying in ...