What is the appropriate treatment for a 60-year-old lady with hypotension (blood pressure 84/50 mmHg), normal electrocardiogram (ECG), being treated with dopamine (intropic agent)?

From the Guidelines

For a 60-year-old lady with hypotension (BP 84/50) and normal ECG, I recommend starting dopamine at 5-10 mcg/kg/min as needed to achieve a target systolic blood pressure of at least 90 mmHg. This recommendation is based on the most recent and highest quality study available, which suggests that dopamine can be used to treat hypotension, especially if it is associated with symptomatic bradycardia 1.

Key Considerations

• The patient's blood pressure should be monitored continuously, checking every 5-15 minutes initially, then hourly once stabilized.
• The infusion should be prepared as 400 mg dopamine in 250 mL of D5W or normal saline (1600 mcg/mL) and administered through a central venous line if possible, or a large peripheral vein if necessary.
• While initiating dopamine, it's crucial to identify and treat the underlying cause of hypotension through additional fluid resuscitation if hypovolemic, antibiotics if septic, or other specific interventions based on etiology.
• Dopamine works at low doses by stimulating dopaminergic receptors, at medium doses by stimulating beta-1 adrenergic receptors to increase cardiac output, and at higher doses by stimulating alpha-adrenergic receptors to cause vasoconstriction, thereby raising blood pressure.

Potential Side Effects

• Tachycardia
• Arrhythmias
• Tissue extravasation It's essential to weigh the benefits and risks of dopamine therapy, considering the patient's individual needs and medical history, as suggested by previous studies 1. However, the most recent study 1 takes precedence in guiding the treatment decision.

From the FDA Drug Label

DOSAGE & ADMINISTRATION ... Begin infusion of dopamine hydrochloride solution at doses of 2 to 5 mcg/kg/min in adult or pediatric patients who are likely to respond to modest increments of heart force and renal perfusion In more seriously ill patients, begin infusion of dopamine hydrochloride at doses of 5 mcg/kg/min and increase gradually, using 5 to 10 mcg/kg/min increments, up to a rate of 20 to 50 mcg/kg/min as needed. The initial dose of dopamine for a 60-year-old lady with low blood pressure (84/50) should be started at 2 to 5 mcg/kg/min and titrated to the desired hemodynamic response.

• The patient's weight is not provided, so the exact dose cannot be calculated.
• The dose should be adjusted according to the patient's response, with careful monitoring of blood pressure, urine output, and cardiac output 2.

From the Research

Treatment of Hypotension

• The patient's blood pressure is 84/50, which is considered hypotensive, and the ECG is normal.
• According to the studies, vasopressors and inotropes are used to treat hypotension in critically ill patients 3, 4, 5, 6, 7.
• Norepinephrine is considered the first-line vasopressor for patients with hypotension, including septic shock and cardiogenic shock 3, 4, 5, 6, 7.

Use of Dopamine

• Dopamine is being used to treat the patient's hypotension.
• However, the studies suggest that dopamine has fallen out of favor as a first-line vasopressor due to its adverse effects 5.
• Low doses of dopamine may be used for inotropic support, but high doses are not recommended due to the risk of adverse events 3.

Alternative Treatment Options

• If the patient's hypotension is not responding to dopamine, alternative vasopressors such as norepinephrine or epinephrine may be considered 3, 4, 5, 6, 7.
• Inotropes such as dobutamine may also be used to increase cardiac output and improve tissue perfusion 3, 4, 7.
• The choice of vasopressor or inotrope should be based on the patient's underlying pathophysiology and the desired pharmacologic effects 6.