Midodrine therapy for vasopressor dependent shock in the intensive care unit: a protocol for a systematic review and meta-analysis

Abstract

IntroductionIntensive care unit (ICU) lengths of stay are modified by ongoing need for haemodynamic support in critically ill patients. This is most commonly provided by intravenous vasopressor therapy. Midodrine has been used as an oral agent for haemodynamic support in patients with orthostatic hypotension or cirrhosis. However, its efficacy in treating shock in the ICU, particularly for patients weaning from intravenous vasopressors, remains uncertain. The objective of this systematic review is to determine the efficacy of midodrine in vasopressor dependent shock.Methods and analysisWe will search Ovid MEDLINE, Ovid Embase, CINAHL and Cochrane Library for observational trials and randomised controlled trials evaluating midodrine in critically ill patients from inception to 21 April 2022. We will also review unpublished data and relevant conference abstracts. Outcomes will include ICU length of stay, duration of intravenous vasopressor support, ICU mortality, hospital mortality, hospital length of stay and rates of ICU readmission. Data will be analysed in aggregate, where appropriate. We will evaluate risk of bias using the modified Cochrane tool and certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations methodology. We will perform trial sequential analysis for the outcome of ICU length of stay.Ethics and disseminationEthics approval is not required as primary data will not be collected. Findings of this review will be disseminated through peer-related publication and will inform future clinical trials.PROSPERO registration numberCRD42021260375.

Midodrine for the early liberation from vasopressor support in the ICU (LIBERATE): A feasibility study

“…However, while identifying midodrine may reduce ICU LOS, duration of IV vasopressor support, and may even decrease hospital mortality, these studies were all underpowered, imprecise, and contained signi cant risks of bias (25). While potentially important, these ndings are based on low certainty of evidence.…”

“…Subsequently, several small randomized controlled trials (RCTs) have evaluated the role of midodrine in critically ill patients. Our study team recently completed a systematic review and meta-analysis to examine the role of midodrine in critically ill patients (25). This review identi ed 6 recent RCTs evaluating the role of midodrine in various critically ill populations (16,(18)(19)(20)(21).…”