Intradialytic hypotension during dialysis adversely affects a patient's prognosis and increases mortality. We report a case in which intradialytic hypotension that persisted after the administration of midodrine was relieved after the use of fludrocortisone. Administration of 0.2 mg of fludrocortisone occurred 30 minutes before dialysis. We compared 45 sessions of dialysis without fludrocortisone administration and 45 sessions of dialysis with fludrocortisone administration in one patient. The number of times in which systolic blood pressure became lower than 80 mmHg and the number of early terminations of dialysis due to a decrease in systolic blood pressure were higher in the sessions without fludrocortisone administration than in the sessions with fludrocortisone administration (P < 0.05). Fludrocortisone may be helpful for the treatment of intradialytic hypotension that does not respond to midodrine administration.
Blood Pressure ; Dialysis ; Fludrocortisone* ; Humans ; Hypotension* ; Midodrine ; Mortality ; Prognosis ; Renal Dialysis

Autonomic dysfunction is a common manifestation in Guillain-Barre syndrome (GBS), but it rarely persists. We report a case involving a 22-year-old man who presented with glove-and-stocking type sensory loss, symmetric weakness, urinary distension, orthostatic hypotension, decreased perspiration, and the syndrome of inappropriate secretion of antidiuretic hormone. He was subsequently diagnosed as having GBS with autonomic failure that persisted for more than six months, despite regaining muscle strength. Orthostatic hypotension progressively improved after rehabilitation and administration of midodrine and fludrocortisone. Extensive evaluation and management should be performed in patients with GBS because severe autonomic dysfunction is a major source of disability.
Fludrocortisone ; Guillain-Barre Syndrome ; Humans ; Hypotension, Orthostatic ; Midodrine ; Muscle Strength ; Young Adult

We report a rare case of a 71-year-old male patient who had suffered from long-lasting neurogenic shock for 13 weeks after cervical spinal cord injury (SCI) caused by a bicycle accident. The neurogenic shock was resolved dramatically 2 weeks after the administration of alpha-1-adrenergic agonist, midodrine hydrochloride. In usual cases, neurogenic shock tends to improve between 2 and 6 weeks after SCI; however, in a few cases, the shock lasts for several months. In our case, spinal shock lasted for 13 weeks and exhibited very sensitive decline of blood pressure for even a slight decrease of dopamine despite recovered bulbospongiosus reflex. Three days after midodrine hydrochloride was added, hypotension improved dramatically. We discuss our rare case with pertinent literatures.
Adrenergic alpha-Agonists ; Aged ; Blood Pressure ; Dopamine ; Humans ; Hypotension ; Male ; Midodrine* ; Reflex ; Shock* ; Spinal Cord Injuries* ; Spinal Cord*

OBJECTIVE: To evaluate the effect of midodrine, an alpha(1) agonist, on symptom and hemodynamic response during standing and arm bicycle ergometer exercise in patients with cervical cord injury. METHOD: Twelve cervical spinal cord injury patients with orthostatic hypotension symptoms and post-exercise hypo- tension were enrolled. They were positioned on a 90degrees standing frame for 3 minutes. After 15 minutes of resting on supine position, 5 minutes of arm bicycle ergometer exercise was done. These tests were done without midodrine initially, but, with 5 mg midodrine on the next day. Heart rate, self-perceived presyncope score (PPS), systolic and diastolic blood pressure were measured before, during and after the exercise. RESULTS: With 5 mg midodrine, the decrease of systolic and diastolic blood pressures after 3 minutes' standing was significantly smaller than without midodrine (p<0.05). PPS was also significantly decreased with midodrine on standing frame test. Arm ergometer exercise induced less systolic blood pressure decrease and better PPS on immediate and 5 minutes after exercise with midodrine (p<0.05). The change of diastolic blood pressure and heart rate was not significant after the exercise with midodrine. CONCLUSION: In cervical spinal cord injury patients with orthostatic and post-exercise hypotension, 5 mg midodrine significantly improved the symptoms and the systolic blood pressures.
Arm ; Blood Pressure ; Heart Rate ; Hemodynamics ; Humans ; Hypotension ; Hypotension, Orthostatic ; Midodrine ; Post-Exercise Hypotension ; Spinal Cord Injuries ; Supine Position ; Syncope

OBJECTIVEThis study was designed to compare the short-term and long-term effects of oral rehydration salts, oral rehydration salts plus metoprolol or oral rehydration salts plus midodrine hydrochloride on the treatment of postural tachycardia syndrome (POTS) in children.

METHODA total of 118 children with POTS were divided into oral rehydration salts group (n = 39), metoprolol group (oral rehydration salts plus metoprolol, n = 10) or midodrine hydrochloride group (oral rehydration salts plus midodrine hydrochloride, n = 69). The patients were followed up in clinics or over telephone for 3 - 18 months, with a mean of (11.7 ± 4.1) months. The symptom scores were recorded before treatment, after 3 months and at the end of the follow-up. Reduction of the score by 2 points or more was considered that the treatment was effective. The effective rate in 3 months was applied to evaluate short-term effects of 3 different therapies by chi-square test. Taking futility as events, Kaplan-Meier curves were drawn to compare long-term effects of the 3 different therapies in treating POTS in children.

RESULTNo significant differences among the 3 groups were found in sex, age, body height, weight, the symptom scores before treatment or hemodynamic variables. Oral rehydration salts, metoprolol and midodrine hydrochloride improved clinical symptoms after 3 months. The symptom scores of the 3 groups before treatment and after 3 months were 2.4 ± 3.2 vs. 5.5 ± 2.9, 2.2 ± 3.0 vs. 6.1 ± 3.0 and 1.9 ± 1.6 vs. 5.9 ± 2.7, respectively. The difference was significant (P < 0.05). Descending order of the short-term effective rate was 91.3% in midodrine hydrochloride group, 80.0% in metoprolol group and 74.4% in oral rehydration salts group. The difference was significant (χ(2) = 5.85, P < 0.05). All the 3 different therapies improved clinical symptoms at the end of follow-up. The symptom scores were 2.6 ± 3.2 vs. 5.6 ± 2.9, 2.5 ± 3.1 vs. 6.1 ± 3.0 and 2.2 ± 2.1 vs. 6.0 ± 2.7, respectively. (P < 0.05). The result of the Kaplan-Meier curves showed that the long-term effect of midodrine hydrochloride was significantly superior to metoprolol group and oral rehydration salts group (P < 0.05). There was no significant difference between the latter two groups.

CONCLUSIONOral rehydration salts plus midodrine hydrochloride or plus metoprolol improved the efficacy of drugs in children with POTS. And the efficacy of midodrine hydrochloride was superior to that of metoprolol.

Adolescent ; Child ; Female ; Humans ; Male ; Metoprolol ; therapeutic use ; Midodrine ; therapeutic use ; Postural Orthostatic Tachycardia Syndrome ; drug therapy ; Prospective Studies ; Treatment Outcome ; Young Adult

OBJECTIVEThe study was designed to examine the effect of selective alpha1 receptor agonist midodrine hydrochloride in the treatment of children with postural orthostatic tachycardia syndrome.

METHODSFifty-five children (23 male, 32 female, age 5 - 19 yrs, mean age 12.3 +/- 3.1 yrs) who came from Peking University First Hospital were included in the study and clinical investigations as well as standing test, basic head-up tilt test and sublingual nitroglycerin-provocated head-up tilt test under quiet circumstance were conducted. They were randomly divided into treatment group (with midodrine hydrochloride and oral rehydration salt treatment) and control group (with oral rehydration salt treatment only). At last, the disease-free rate, improvement rate and effective rate of symptoms, and the rate of HUT from positive to negative response were compared between control group and treatment group. SPSS 10.0 software was used for the statistical analysis of these data.

RESULTSThe symptom improvement rate in treatment group was significantly higher than that of control group after three and six weeks of treatment (100.0% vs. 42.4%, P < 0.001; 100.0% vs. 42.4%, chi2 = 19.352, P < 0.001). The disease-free rate at follow-up end-point in treatment group was significantly higher than that of control group (77.3% vs. 27.3%, chi2 = 13.239, P < 0.001). The effective rate at follow-up end-point in treatment group was also significantly higher than that of control group (100.0% vs. 36.4%, chi2 = 22.647, P < 0.001). The rate of HUT changing from positive to negative response between two groups after three weeks of treatment was not significantly different (31.8% vs. 12.1%, P > 0.05), but it was significantly different (81.0% vs. 48.5%, P < 0.05) after six weeks of treatment.

CONCLUSIONSelective alpha1 receptor agonist midodrine hydrochloride is effective in the treatment of children with postural orthostatic tachycardia syndrome.

Adolescent ; Adrenergic alpha-Agonists ; therapeutic use ; Child ; Child, Preschool ; Female ; Humans ; Male ; Midodrine ; therapeutic use ; Postural Orthostatic Tachycardia Syndrome ; drug therapy ; Treatment Outcome ; Young Adult

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.
Adrenergic alpha-Agonists ; Aged ; Blood Pressure ; Dislocations ; Dopamine ; Humans ; Hypotension* ; Infusions, Intravenous ; Midodrine* ; Motor Vehicles ; Quadriplegia ; Reflex ; Rehabilitation ; Spinal Cord ; Spinal Cord Injuries ; Sympathetic Nervous System

OBJECTIVE: To analyze the disease spectrums underlying orthostatic intolerance (OI) and sitting intolerance (SI) in Chinese children, and to understand the clinical empirical treatment options. METHODS: The medical records including history, physical examination, laboratory examination, and imagological examination of children were retrospectively studied in Peking University First Hospital from 2012 to 2021. All the children who met the diagnostic criteria of OI and SI were enrolled in the study. The disease spectrums underlying OI and SI and treatment options during the last 10 years were analyzed. RESULTS: A total of 2 110 cases of OI and SI patients were collected in the last 10 years, including 943 males (44.69%) and 1 167 females (55.31%) aged 4－18 years, with an average of (11.34±2.84) years. The overall case number was in an increasing trend over the year. In the OI spectrum, postural tachycardia syndrome (POTS) accounted for 826 cases (39.15%), followed by vasovagal syncope (VVS) (634 cases, 30.05%). The highest proportion of SI spectrum was sitting tachycardia (STS) (8 cases, 0.38%), followed by sitting hypertension (SHT) (2 cases, 0.09%). The most common comorbidity of OI and SI was POTS coexisting with STS (36 cases, 1.71%). The highest proportion of treatment options was autonomic nerve function exercise (757 cases, 35.88%), followed by oral rehydration salts (ORS) (687 cases, 32.56%), metoprolol (307 cases, 14.55%), midodrine (142 cases, 6.73%), ORS plus metoprolol (138 cases, 6.54%), and ORS plus midodrine (79 cases, 3.74%). The patients with POTS coexisting with VVS were more likely to receive pharmacological intervention than the patients with POTS and the patients with VVS (41.95% vs. 30.51% vs. 28.08%, χ²= 20.319, P < 0.01), but there was no significant difference in the proportion of treatment options between the patients with POTS and the patients with VVS. CONCLUSION POTS and VVS in children are the main underlying diseases of OI, while SI is a new disease discovered recently. The number of children with OI and SI showed an increasing trend. The main treatment methods are autonomic nerve function exercise and ORS. Children with VVS coexisting with POTS were more likely to take pharmacological treatments than those with VVS or POTS only.
Child ; Electrolytes ; Female ; Humans ; Male ; Metoprolol ; Midodrine ; Orthostatic Intolerance/therapy* ; Postural Orthostatic Tachycardia Syndrome/diagnosis* ; Retrospective Studies ; Salts ; Sitting Position ; Syncope, Vasovagal/diagnosis* ; Tilt-Table Test

BACKGROUNDOrthostatic intolerance (OI) is a common disease at pediatric period which has a serious impact on physical and mental health of children. The purpose of this study was to investigate the effect of related factors on the prognosis of children with OI.

METHODSThe subjects were 170 children with OI, including 71 males (41.8%) and 99 females (58.2%) with age from 6 to 17 (12.0±2.6) years. The effect of related factors on the prognosis of children was studied by using univariate analysis. Then, the impact of children's age, symptom score, duration, disease subtype, and treatment on patient's prognosis was studied via analysis of COX proportional conversion model.

RESULTSAmong 170 cases, 48 were diagnosed with vasovagal syncope, including 28 cases of vasoinhibitory type, 16 cases of mixed type, and 4 cases of cardioinhibitory type; 115 cases were diagnosed with postural tachycardia syndrome and 7 cases with orthostatic hypotension. By using univariate analysis of Cox regression, the results showed that symptom score had a marked impact on the time of symptoms improvement of children after taking medication (P < 0.05), while other univariates had no impact (P > 0.05). Multivariate analysis using Cox proportional hazards regression model showed that the symptom score at diagnosis had a significant effect on holding time of symptoms improvement of children after taking medication (P < 0.05). Kaplan-Meier curve showed that symptom-free survival was higher in children with symptom score equal to 1 than children with symptom score equal to or greater than 2 during follow-up (P < 0.05).

CONCLUSIONSymptom score is an important factor affecting the time of symptom improvement after treatment for children with OI.

Adolescent ; Child ; Female ; Humans ; Male ; Metoprolol ; therapeutic use ; Midodrine ; therapeutic use ; Orthostatic Intolerance ; diagnosis ; drug therapy ; mortality ; pathology ; Prognosis ; Proportional Hazards Models ; Retrospective Studies ; Saline Waters ; therapeutic use ; Syncope, Vasovagal ; diagnosis ; drug therapy ; mortality ; pathology

Nonocclusive mesenteric ischemia (NOMI) is known to occupy about 25+ACU- to 60+ACU- of intestinal infarction. NOMI has been reported to be responsible for 9+ACU- of the deaths in the dialysis population and the postulated causes of NOMI include intradialytic hypotension, atherosclerosis and medications, such as diuretics, digitalis and vasopressors. Clinical manifestations, such as fever, diarrhea and leukocytosis, are nonspecific, which makes early diagnosis of NOMI very difficult. Case: A 66-year-old woman on maintenance hemodialysis for 5 years was admitted with syncope, abdominal pain and chilly sensation. Since 7 days prior to admission, blood pressure on the supine position during hemodialysis had frequently fallen to 80/50 mmHg. Four days later, she complained of progressive abdominal pain. Rebound tenderness and leukocytosis (WBC 13900/mm3) with left shift were noted. Stool examination was positive for occult blood. Abdominal CT scan showed a distended gall bladder with sludge. Under the impression of acalculous cholecystitis, she was operated on. Surgical and pathologic findings of colon colon were compatible with NOMI. Because of recurrent intradialytic hypotension, we started midodrine 2.5 mg just before hemodialysis and increased the dose up to 7.5 mg. After midodrine therapy, blood pressure during dialysis became stable and the symptoms associated with hypotension did not recur. CONCLUSION: As NOMI may occur within several hours or days after an intradialytic hypotensive episode, abdominal pain should be carefully observed and NOMI should be considered as a differential diagnosis. In addition, we suggest that midodrine be considered to prevent intradialytic hypotensive episodes.
Aged ; Case Report ; Colectomy ; Colon/surgery ; Colon/blood supply ; Female ; Human ; Ischemia/therapy ; Ischemia/pathology ; Ischemia/etiology+ACo- ; Kidney Failure, Chronic/therapy ; Mesentery/blood supply+ACo- ; Midodrine/administration +ACY- dosage ; Renal Dialysis/methods ; Renal Dialysis/adverse effects+ACo- ; Treatment Outcome ; Vasoconstrictor Agents/administration +ACY- dosage