When is initiating dobutamine (dobutamine hydrochloride) more favorable than starting norepinephrine (levophed) infusion in cases of hypotension?

From the Guidelines

Dobutamine is more favorable than norepinephrine in situations where cardiac output needs to be increased without significant vasoconstriction, such as in patients showing evidence of persistent hypoperfusion despite adequate fluid loading and the use of vasopressor agents. This is based on the suggestion to use dobutamine in such patients, as stated in the 2016 surviving sepsis campaign guidelines 1. Specifically, dobutamine is preferred in cases where myocardial dysfunction is suspected, as indicated by elevated cardiac filling pressures and low cardiac output, or in the presence of ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (MAP) 1.

The use of dobutamine is beneficial in scenarios where increasing cardiac output is crucial, such as in cardiogenic shock or heart failure exacerbations with adequate blood pressure but reduced cardiac output. It is also effective in right ventricular failure, particularly in settings of pulmonary hypertension, as it improves right ventricular function while potentially reducing pulmonary vascular resistance. In septic shock patients who remain hypoperfused despite adequate fluid resuscitation and blood pressure support with norepinephrine, adding dobutamine can improve tissue perfusion, as suggested by the guidelines 1.

Key points to consider when using dobutamine include:

• Starting dose: typically 2-5 mcg/kg/min, titrated up to 20 mcg/kg/min based on hemodynamic response
• Mechanism of action: primarily stimulates beta-1 receptors to increase cardiac contractility and heart rate, with mild beta-2 effects causing vasodilation
• Caution in patients with severe hypotension due to potential worsening of hypotension from vasodilatory effects
• Increased myocardial oxygen demand, which could be problematic in patients with coronary artery disease

Overall, the decision to use dobutamine over norepinephrine should be based on the individual patient's hemodynamic profile and the need to improve cardiac output without causing significant vasoconstriction, as guided by the most recent and relevant clinical guidelines 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY Dobutamine is a direct-acting inotropic agent whose primary activity results from stimulation of the β receptors of the heart while producing comparatively mild chronotropic, hypertensive, arrhythmogenic, and vasodilative effects. In patients with depressed cardiac function, both dobutamine and isoproterenol increase the cardiac output to a similar degree In the case of dobutamine, this increase is usually not accompanied by marked increases in heart rate (although tachycardia is occasionally observed), and the cardiac stroke volume is usually increased.

The situations where starting dobutamine over norepinephrine drip is more favorable include:

• Patients with depressed cardiac function who require an increase in cardiac output without a significant increase in heart rate.
• Cases where vasodilation is desired, as dobutamine produces mild vasodilative effects.
• Situations where increased cardiac stroke volume is necessary, as dobutamine typically increases stroke volume without marked increases in heart rate. 2

From the Research

Situations where starting dobutamine over norepinephrine drip is more favorable

• In cases where norepinephrine fails to restore perfusion, dobutamine represents the first-line agent 3
• When the primary goal is to increase cardiac output and improve tissue perfusion, dobutamine may be preferred over norepinephrine 4
• In patients with congestive heart failure, dobutamine can be used to improve cardiac output and decrease pulmonary wedge pressure, with clinical benefits observed to continue for weeks to months following discontinuation 5
• In experimental cardiogenic shock, combined dobutamine-norepinephrine therapy has been shown to restore ventriculoarterial matching and improve cardiac output and central venous oxygen saturation 6

Comparison with other inotropic agents

• Levosimendan may reduce short-term mortality compared to dobutamine, but this benefit is not confirmed on long-term follow-up 7
• There is uncertainty regarding the effect of other inotropic agents, such as epinephrine, amrinone, and dopexamine, due to limited evidence and high risk of bias 7

Clinical considerations

• The choice of inotropic agent should be based on individual patient needs and hemodynamic goals 4
• Early goal-directed therapy with haemodynamic stabilisation within predefined timelines may be a useful approach in cardiogenic shock and low cardiac output syndrome 7