What are the indications to start a dopamine (DA) drip for hypotension?

From the Guidelines

Dopamine drip is indicated for the treatment of shock states with hypotension, particularly in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia, as an alternative to norepinephrine 1. The typical starting dose is 5-10 mcg/kg/min, as indicated in the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.

• Dopamine primarily affects dopaminergic receptors at lower doses, improving renal and mesenteric blood flow.
• At intermediate doses, it stimulates beta-1 adrenergic receptors, increasing cardiac contractility and heart rate.
• At higher doses, alpha-adrenergic effects predominate, causing vasoconstriction. It's essential to note that norepinephrine is now often preferred as first-line vasopressor therapy in many shock states due to fewer arrhythmogenic effects and more predictable hemodynamic response than dopamine 1. Some key points to consider when using dopamine include:
• It should be used as an alternative vasopressor agent to norepinephrine only in highly selected patients 1.
• Low-dose dopamine should not be used for renal protection, as recommended by the Surviving Spsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 1.
• Dopamine requires central venous access for administration and continuous cardiac monitoring.
• The dosing should be titrated to an end point reflecting perfusion, and the agent reduced or discontinued in the face of worsening hypotension or arrhythmias 1.

From the FDA Drug Label

When indicated, restoration of circulatory volume should be instituted or completed with a suitable plasma expander or whole blood, prior to administration of dopamine hydrochloride. Patients most likely to respond to dopamine are those whose physiological parameters (such as urine flow, myocardial function and blood pressure) have not undergone extreme deterioration Poor Perfusion of Vital Organs: Although urine flow is apparently one of the better diagnostic signs for monitoring vital organ perfusion, the physician also should observe the patient for signs of reversal of mental confusion or coma. Low Cardiac Output: Dopamine's direct inotropic effect on the myocardium which increases cardiac output at low or moderate doses is related to a favorable prognosis Hypotension: Low to moderate doses of dopamine, which have little effect on SVR, can be used to manage hypotension due to inadequate cardiac output

The indications to start a dopamine drip include:

• Poor perfusion of vital organs, as evidenced by decreased urine flow, mental confusion, or coma
• Low cardiac output, as indicated by decreased cardiac output and increased systemic vascular resistance
• Hypotension, due to inadequate cardiac output or diminished systemic vascular resistance
• Patients with decreased systolic and diastolic blood pressure, where a definite trend toward decreased blood pressure becomes apparent 2
• Patients who have not undergone extreme deterioration of physiological parameters such as urine flow, myocardial function, and blood pressure 2

From the Research

Indications for Dopamine Drip

The following are indications for starting a dopamine drip:

• Septic shock with myocardial dysfunction, as dopamine infusion has been shown to improve haemodynamic parameters such as cardiac output, stroke volume, and mean arterial pressure 3
• Prophylaxis for deterioration and/or improvement of kidney- and bowel perfusion in critically-ill patients, although the effectiveness of this approach has been questioned 4
• Cardiogenic shock, as dopamine can increase cardiac output and blood pressure, although norepinephrine may be more effective in some cases 5, 6
• Sepsis with preexisting or acute heart failure, as dopamine may be associated with shorter ICU and hospital stays, although norepinephrine plus vasopressin may be associated with reduced survival 7

Contraindications and Considerations

When considering starting a dopamine drip, the following should be taken into account:

• Risk of increasing preload in patients with previous myocardial disease 3
• Risk of increasing intrapulmonary shunting in hypoxaemic patients 3
• Potential for arrhythmias, although the incidence of arrhythmia may not be different between dopamine and norepinephrine 5, 6
• The need for careful monitoring of haemodynamic parameters and adjustment of the dopamine dose as needed 3, 4