From the Guidelines
Epinephrine should be added to dobutamine in cardiogenic shock when there is persistent hypotension despite adequate dobutamine therapy, as it provides both potent inotropic and vasopressor effects, increasing cardiac contractility and systemic vascular resistance. Typically, dobutamine (starting at 2-5 mcg/kg/min, titrated up to 20 mcg/kg/min) is the initial inotropic agent of choice for cardiogenic shock with adequate blood pressure 1. However, when systolic blood pressure remains below 90 mmHg despite optimal dobutamine dosing, epinephrine (starting at 0.01-0.03 mcg/kg/min, titrated as needed) should be added, as recommended by the European Society of Cardiology 1. This combination is particularly beneficial in severe cardiogenic shock with profound hypotension. The alpha-adrenergic effects of epinephrine help maintain coronary perfusion pressure while its beta-adrenergic effects complement dobutamine's inotropic action.
Some key points to consider when using epinephrine and dobutamine in combination include:
- Close hemodynamic monitoring is essential, including continuous blood pressure measurement, cardiac output assessment, and evaluation for tachyarrhythmias, myocardial ischemia, and lactic acidosis, which are potential complications of high-dose catecholamine therapy 1.
- The use of epinephrine may be associated with a higher risk of tachycardia and arrhythmias than norepinephrine 1.
- Device therapy, such as intra-aortic balloon pump (IABP) or percutaneous left ventricular assist device (LVAD), should be considered when there is inadequate response to combination therapy 1.
Overall, the addition of epinephrine to dobutamine in cardiogenic shock with persistent hypotension can be a lifesaving intervention, but it requires careful monitoring and consideration of potential complications.
From the Research
Use of Epinephrine in Cardiogenic Shock with Dobutamine
- Epinephrine may be added to dobutamine in cardiogenic shock when tissue and organ perfusion remain inadequate despite the use of dobutamine 2.
- The combination of norepinephrine and dobutamine appears to be a more reliable and safer strategy than epinephrine alone, as epinephrine is associated with a transient lactic acidosis, higher heart rate, and arrhythmia, and inadequate gastric mucosa perfusion 3.
- Epinephrine use in cardiogenic shock has been associated with a threefold increase in the risk of death, and its use should be avoided if possible 4.
- Low-dose dobutamine may be used as an initial inotropic support in acute myocardial infarction patients with intermediate to high risk of cardiogenic shock development, but the addition of epinephrine is not recommended unless necessary 5.
- The choice of inotrope therapy, including the addition of epinephrine to dobutamine, should be based on individual patient needs and hemodynamic status, and should take into account the potential risks and benefits of each therapy 2, 3, 6.