What are the situations where initiating a dopamine (DA) drip is harmful or contraindicated?

From the Guidelines

Starting a dopamine drip is harmful or contraindicated in patients with pheochromocytoma, tachyarrhythmias, severe hypovolemia, ventricular fibrillation, peripheral vascular disease, and sulfite allergies, as well as those with severe coronary artery disease. When considering the initiation of dopamine, it is crucial to weigh the potential benefits against the risks, particularly in specific clinical situations.

• Patients with pheochromocytoma should not receive dopamine as it can trigger dangerous catecholamine surges, potentially causing hypertensive crisis, as suggested by the management of hypertensive emergencies 1.
• Those with tachyarrhythmias may experience worsening of their condition as dopamine can increase heart rate and trigger arrhythmias, especially at higher doses (>10 mcg/kg/min).
• Patients with severe hypovolemia should have volume replacement before dopamine initiation, as the drug may mask underlying volume depletion and worsen tissue perfusion.
• Dopamine is also contraindicated in ventricular fibrillation until after defibrillation attempts.
• In patients with peripheral vascular disease or vasospastic conditions, dopamine can worsen tissue perfusion through vasoconstriction, potentially leading to tissue ischemia or necrosis, particularly in extremities.
• Caution is needed in patients with sulfite allergies as many dopamine preparations contain sulfites.
• For patients with severe coronary artery disease, dopamine's increased myocardial oxygen demand may precipitate ischemia, and alternative treatments such as nitroglycerine and aspirin should be considered 1. The Surviving Sepsis Campaign guidelines also recommend against using low-dose dopamine for renal protection, suggesting instead the use of alternative vasopressors and inotropes, such as norepinephrine and dobutamine, in specific clinical scenarios 1. When administering dopamine, it is essential to use a central line for higher concentrations, start at low doses (2-5 mcg/kg/min), titrate carefully, and monitor for extravasation which can cause tissue necrosis.

From the FDA Drug Label

Dopamine hydrochloride should not be used in patients with pheochromocytoma. Dopamine should not be administered in the presence of uncorrected tachyarrhythmias or ventricular fibrillation.

Solutions containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus.

Hypoxia, Hypercapnia, Acidosis: These conditions, which may also reduce the effectiveness and/or increase the incidence of adverse effects of dopamine, must be identified and corrected prior to, or concurrently with, administration of dopamine HCl.

Patients with a history of occlusive vascular disease (e.g., arteriosclerosis, arterial embolism, Raynaud's disease, cold injury such as frostbite, diabetic endarteritis, and Buerger's disease) should be closely monitored for any changes in color or temperature of the skin of the extremities

Dopamine Hydrochloride in 5% Dextrose Injection, USP should be infused into a large vein whenever possible to prevent the possibility of infiltration of perivascular tissue adjacent to the infusion site.

Administration into an umbilical arterial catheter is not recommended.

The situations where starting a dopamine drip is harmful or contraindicated include:

• Pheochromocytoma: Dopamine should not be used in patients with this condition 2.
• Uncorrected tachyarrhythmias or ventricular fibrillation: Dopamine should not be administered in these situations 2.
• Subclinical or overt diabetes mellitus: Solutions containing dextrose should be used with caution in these patients 2.
• Hypoxia, Hypercapnia, Acidosis: These conditions should be identified and corrected before administering dopamine 2.
• Occlusive vascular disease: Patients with this condition should be closely monitored for changes in skin color or temperature of the extremities 2.
• Infiltration of perivascular tissue: Dopamine should be infused into a large vein to prevent this complication 2, 2.
• Umbilical arterial catheter: Administration through this route is not recommended 2, 2.

From the Research

Situations Where Starting Dopamine Drip is Harmful or Contraindicated

• Pheochromocytoma: Starting a dopamine drip in patients with pheochromocytoma can be harmful as these tumors produce catecholamines, including epinephrine and norepinephrine, which can cause potentially lethal arrhythmias 3.
• Dopamine-secreting pheochromocytomas: In these cases, alpha-blockade is not indicated as it may lead to hypotension and cardiovascular collapse, and dopamine-secreting tumors are less likely to enhance with metaiodobenzylguanidine (MIBG) scanning 4.
• Pseudopheochromocytoma: Patients with pseudopheochromocytoma may have elevated dopamine levels, and starting a dopamine drip can exacerbate the condition 5, 6.
• Malignant pheochromocytoma: High circulating levels of dopamine are more often associated with malignant rather than benign pheochromocytomas, and starting a dopamine drip can worsen the condition 7.
• Idiopathic hypovolemia, mastocytosis, neurogenic hypertension, and cocaine abuse: These conditions can mimic pheochromocytoma symptoms, and starting a dopamine drip can lead to incorrect diagnosis and treatment 6.