Midodrine administration during critical illness: fixed-dose or titrate to response?

Dear Editor, We read with interest the multicenter, randomized, double-blind, placebo-controlled trial conducted by Santer and colleagues examining midodrine administration to expedite weaning of intravenous vasopressor medications [[1]]. In a heterogeneous cohort of 132 critically ill patients enrolled in three centers over 81 months, the investigators concluded midodrine administration (20 mg every 8 h) was ineffective at hastening time to discontinuation of single intravenous vasopressor medication compared to placebo (23.5 vs. 22.5 h; I p i = 0.62), and caused significantly more bradycardia (7.6% vs. 0%; I p i = 0.02). We thank Santer et al. for their report, but wonder if their conclusions would be better framed as "midodrine at a fixed-dose among patients receiving single vasopressor therapy was not effective at reducing the time to pressor discontinuation"?. [Extracted from the article]