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Case Report
Neurosurgery
Use of droxidopa for blood pressure augmentation after acute spinal cord injury: case reports
Christopher S. Hong, Muhammad K. Effendi, Abdalla A. Ammar, Kent A. Owusu, Mahmoud A. Ammar, Andrew B. Koo, Layton A. Lamsam, Aladine A. Elsamadicy, Gregory A. Kuzmik, Maxwell Laurans, Michael L. DiLuna, Mark L. Landreneau
Received December 3, 2021  Accepted September 14, 2022  Published online December 7, 2022  
DOI: https://doi.org/10.4266/acc.2021.01662    [Epub ahead of print]
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AbstractAbstract PDF
Hypotension secondary to autonomic dysfunction is a common complication of acute spinal cord injury (SCI) that may worsen neurologic outcomes. Midodrine, an enteral α-1 agonist, is often used to facilitate weaning intravenous (IV) vasopressors, but its use can be limited by reflex bradycardia. Alternative enteral agents to facilitate this wean in the acute post-SCI setting have not been described. We aim to describe novel application of droxidopa, an enteral precursor of norepinephrine that is approved to treat neurogenic orthostatic hypotension, in the acute post-SCI setting. Droxidopa may be an alternative enteral therapy for those intolerant of midodrine due to reflex bradycardia. We describe two patients suffering traumatic cervical SCI who were successfully weaned off IV vasopressors with droxidopa after failing with midodrine. The first patient was a 64-year-old male who underwent C3–6 laminectomies and fusion after a ten-foot fall resulting in quadriparesis. Post-operatively, the addition of midodrine in an attempt to wean off IV vasopressors resulted in significant reflexive bradycardia. Treatment with droxidopa facilitated rapidly weaning IV vasopressors and transfer to a lower level of care within 72 hours of treatment initiation. The second patient was a 73-year-old male who underwent C3–5 laminectomies and fusion for a traumatic hyperflexion injury causing paraplegia. The addition of midodrine resulted in severe bradycardia, prompting consideration of pacemaker placement. However, with the addition of droxidopa, this was avoided, and the patient was weaned off IV vasopressors on dual oral therapy with midodrine and droxidopa. Droxidopa may be a viable enteral therapy to treat hypotension in patients after acute SCI who are otherwise not tolerating midodrine in order to wean off IV vasopressors. This strategy may avoid pacemaker placement and facilitate shorter stays in the intensive care unit, particularly for patients who are stable but require continued intensive care unit admission for IV vasopressors, which can be cost ineffective and human resource depleting.
Original Article
Midodrine for the Treatment of Hypotension in a Tetraplegic Patient with Cervical Cord Injury in ICU: A case report
Dong Woo Han, Shin Ok Koh, Yong Keyong Lee, Man Woo Lee
Korean J Crit Care Med. 2002;17(2):119-122.
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AbstractAbstract PDF
Cervical spinal cord injury results in significant dysfunction of the sympathetic nervous system. Reduced sympathetic activity below the level of spinal cord injury is associated with low resting blood pressure,orthostatic hypotension,and reflex bradycardia.Hypotension can be treated with vasoactive agents,such as dopamine,epinephrine,norepinephrine, and phenylephine .Orally administered midodrine is an alpha adrenergic receptor agonist that increases blood pressure with vasoconstriction.Its action is fast and effective in treating hypotension in patients with spinal cord injury,and it has less severe side effects.A 70-year-old tetraplegic patient with fracture and dislocation of C6-7 after a motor vehicle accident was admitted to ICU and underwent anterior cervical intervertebral body fusion.Symptomatic hypotension following postural changes was treated with intravenous infusion of dopamine,but it was difficult to reduce the dose of dopamine without causing severe hypotension.Midodrine was prescribed and the patient was well tolerated without any adverse effect.With adequately maintained blood pressure,intravenous infusion of dopamine was successfully switched to the oral midodrine.This case suggests that the midodrine is effective for the treatment of hypotension in tetraplegic patients with spinal cord injury and enables patients to participate in early rehabilitation therapies.

ACC : Acute and Critical Care