Is dobutamine (a beta-adrenergic agonist) helpful in managing right ventricular (RV) infarction complicated by shock?

From the Guidelines

Dobutamine can be helpful in managing right ventricular (RV) infarct with shock, but it should be used cautiously and as part of a comprehensive treatment approach. For RV infarct with cardiogenic shock, initial management should focus on volume loading with IV fluids (typically 1-2 liters of normal saline) to maintain adequate RV preload, as RV infarcts are preload-dependent 1. If shock persists despite adequate volume resuscitation, dobutamine at doses of 2-20 mcg/kg/min can be beneficial due to its positive inotropic effects that improve RV contractility without significantly increasing pulmonary vascular resistance. The use of dobutamine in this context is supported by guidelines that recommend its use in patients with hypotension and/or hypoperfusion to increase cardiac output and improve peripheral perfusion 1. However, dobutamine may cause hypotension through peripheral vasodilation, so it's often combined with norepinephrine (starting at 0.01-0.3 mcg/kg/min) to maintain adequate systemic blood pressure.

Some key points to consider when using dobutamine in RV infarct with shock include:

• Initial volume loading with IV fluids to maintain adequate RV preload
• Use of dobutamine at doses of 2-20 mcg/kg/min to improve RV contractility
• Combination with norepinephrine to maintain adequate systemic blood pressure
• Continuous hemodynamic monitoring to guide therapy
• Goal of maintaining adequate cardiac output while avoiding excessive RV afterload

It's also important to note that dobutamine works by stimulating beta-1 receptors to increase myocardial contractility, while its modest beta-2 effects help reduce pulmonary vascular resistance, making it particularly suitable for RV dysfunction when compared to agents with more alpha effects that might increase RV afterload 1. Overall, the use of dobutamine in RV infarct with shock should be guided by the principles of maintaining adequate cardiac output and perfusion, while minimizing the risk of adverse effects.

From the Research

RV Infarct with Shock and Dobutamine Use

• The use of dobutamine in patients with right ventricular infarct complicated by cardiogenic shock has been studied in various research papers 2, 3, 4.
• A study published in the Archives of Internal Medicine in 1981 found that the simultaneous use of counterpulsation and dobutamine therapy resulted in a substantial increase in cardiac output in a patient with right ventricular infarct complicated by shock 2.
• Another study published in the Journal of the American Heart Association in 2021 found that dobutamine was associated with increased rates of adverse clinical outcomes in cardiogenic shock, including all-cause mortality, mechanical circulatory support, and renal replacement therapy 3.
• A systematic review and meta-analysis published in Critical Care Explorations in 2023 compared the efficacy and safety of dobutamine and milrinone in patients with cardiogenic shock, and found that milrinone was associated with reduced all-cause mortality, while dobutamine was associated with a shorter hospital length of stay 4.
• Other studies have discussed the management of right ventricular infarction shock, including the use of vasoactive drugs, thrombolysis, and percutaneous coronary interventionism 5, 6.
• The use of dobutamine in right ventricular infarct with shock is not universally recommended, and its efficacy and safety should be carefully considered in each individual case 2, 3, 4.