Hong Christopher S, Effendi Muhammad K, Ammar Abdalla A, Owusu Kent A, Ammar Mahmoud A, Koo Andrew B, Lamsam Layton A, Elsamadicy Aladine A, Kuzmik Gregory A, Laurans Maxwell, DiLuna Michael L, Landreneau Mark L
Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.
Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA.
Acute Crit Care. 2025 Feb;40(1):138-143. doi: 10.4266/acc.2021.01662. Epub 2022 Dec 7.
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.
自主神经功能障碍继发的低血压是急性脊髓损伤（SCI）的常见并发症，可能会使神经功能预后恶化。米多君是一种肠道α-1激动剂，常用于促进静脉血管升压药的撤机，但它的使用可能会受到反射性心动过缓的限制。在急性脊髓损伤后的情况下，尚未有用于促进撤机的替代肠道药物的相关描述。我们旨在描述去氧肾上腺素（一种已获批准用于治疗神经源性直立性低血压的肠道去甲肾上腺素前体）在急性脊髓损伤后的新应用。对于因反射性心动过缓而不耐受米多君的患者，去氧肾上腺素可能是一种替代的肠道治疗方法。我们描述了两名患有创伤性颈髓损伤的患者，他们在使用米多君失败后，成功地通过去氧肾上腺素撤掉了静脉血管升压药。第一名患者是一名64岁男性，在从十英尺高处坠落导致四肢瘫痪后接受了C3 - 6椎板切除术和融合术。术后，为了撤掉静脉血管升压药而加用米多君导致了明显的反射性心动过缓。使用去氧肾上腺素治疗促进了静脉血管升压药的快速撤机，并在开始治疗后72小时内转至较低级别的护理。第二名患者是一名73岁男性，因创伤性屈曲损伤导致截瘫而接受了C3 - 5椎板切除术和融合术。加用米多君导致严重心动过缓，促使考虑植入起搏器。然而，加用去氧肾上腺素后避免了这种情况，患者通过米多君和去氧肾上腺素的联合口服治疗撤掉了静脉血管升压药。对于急性脊髓损伤后不能耐受米多君以撤掉静脉血管升压药的患者，去氧肾上腺素可能是一种可行的肠道治疗方法。这种策略可能避免植入起搏器，并有助于缩短在重症监护病房的停留时间，特别是对于那些病情稳定但因静脉血管升压药而需要继续入住重症监护病房的患者，这可能会导致成本效益低下和人力资源消耗。
