In what situation is dopamine superior to other drugs?

From the Guidelines

Dopamine is superior to other drugs in situations where patients have a low risk of tachyarrhythmias and absolute or relative bradycardia, as it can be used as an alternative vasopressor agent to norepinephrine in these highly selected patients. According to the most recent and highest quality study available, dopamine can be used in specific situations where its unique properties can be beneficial 1.

Key Points to Consider

• Dopamine can increase blood pressure, improve renal perfusion, and maintain cardiac output when other vasopressors may be insufficient.
• Its use should be limited to intensive care settings with continuous monitoring of vital signs.
• Dopamine should be gradually decreased rather than abruptly stopped to avoid rebound hypotension.
• The use of dopamine is generally reserved for patients with bradycardia or low risk for tachycardia, as it can stimulate dopaminergic, alpha, and beta-adrenergic receptors, offering a unique positive inotropic effect and renal vasodilation at low doses.

Clinical Context

In clinical practice, the choice of vasopressor agent depends on the individual patient's condition and the underlying cause of shock. While norepinephrine is generally recommended as the first-line vasopressor, dopamine may be considered in specific situations where its properties can be beneficial, such as in patients with bradycardia or low risk for tachycardia 1.

Evidence-Based Recommendation

Based on the available evidence, dopamine can be considered a superior option to other drugs in highly selected patients with specific conditions, such as bradycardia or low risk for tachycardia, where its unique properties can be beneficial. However, its use should be carefully considered and monitored in an intensive care setting to minimize potential risks and optimize patient outcomes 1.

From the FDA Drug Label

Dopamine Hydrochloride in 5% Dextrose Injection, USP is indicated for the correction of hemodynamic imbalances present in shock due to myocardial infarction, trauma, endotoxic septicemia, open heart surgery, renal failure and chronic cardiac decompensation as in refractory congestive failure 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 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. Reported studies indicate that when dopamine is administered before urine flow has decreased to approximately 0. 3 mL/minute prognosis is more favorable.

Dopamine is superior to other drugs in situations where rapid correction of hemodynamic imbalances is necessary, such as:

• Shock due to myocardial infarction, trauma, endotoxic septicemia, open heart surgery, renal failure, and chronic cardiac decompensation
• Poor perfusion of vital organs, as evidenced by decreased urine flow, mental confusion, or coma
• Low cardiac output, where dopamine's direct inotropic effect can increase cardiac output and improve renal blood flow
• Hypotension due to inadequate cardiac output or diminished systemic vascular resistance

In these situations, dopamine's unique mechanism of action, which includes increasing cardiac output, renal blood flow, and vascular resistance, makes it a preferred choice over other drugs 2, 2.

From the Research

Situation Where Dopamine is Superior

• Dopamine is superior to other drugs in the treatment of shock and refractory heart failure due to its ability to directly dilate mesenteric, renal, and cerebral vessels and redirect blood flow to essential viscera 3.
• Dopamine has a significant beta-adrenergic, inotropic effect, increasing myocardial contractility, which is equivalent to that of isoproterenol, epinephrine, and norepinephrine, but with less frequent tachycardia, tachyarrhythmias, and angina 3.
• Dopamine is a logical first-choice catecholamine for treatment of shock and refractory heart failure because it increases myocardial contractility, selectively redistributes perfusion to essential viscera, and allows a pharmacologic titration of effect 3.

Comparison with Other Vasopressors

• A study comparing dopamine and norepinephrine in the treatment of shock found that there was no significant difference in the rate of death at 28 days, but dopamine was associated with more arrhythmic events 4.
• Another study found that norepinephrine-dobutamine was a more reliable and safer strategy than epinephrine in cardiogenic shock, with less lactic acidosis, lower heart rate, and fewer arrhythmias 5.
• A retrospective review of patients with cardiogenic shock found that the use of norepinephrine as a first-line vasopressor was not associated with reductions in in-hospital mortality or arrhythmia, but could reduce the use of additional vasopressors 6.
• A review of vasopressor therapy in critically ill patients with shock found that dopamine is recommended only in bradycardic patients, and norepinephrine is the first-choice vasopressor in vasodilatory shock after adequate volume resuscitation 7.