What is the role of dobutamine in pediatric cardiogenic shock?

From the Guidelines

Dobutamine is a recommended inotropic agent for treating pediatric cardiogenic shock, as it improves hemodynamics in children with this condition, as shown in several studies 1. The use of dobutamine in pediatric cardiogenic shock is supported by evidence from multiple studies, including those published in 2010 1 and more recently in 2020 1.

Key Points to Consider

• Dobutamine works by stimulating beta-1 adrenergic receptors in the heart, increasing cardiac contractility and output without significantly increasing heart rate or blood pressure at lower doses.
• Administration requires central venous access and continuous cardiac monitoring.
• Dobutamine is particularly useful in situations where increased contractility is needed without substantial vasoconstriction, such as in viral myocarditis, post-cardiac surgery, or dilated cardiomyopathy.
• It can be combined with vasopressors like norepinephrine if additional blood pressure support is required.
• Potential side effects include tachycardia, arrhythmias, and hypotension, especially at higher doses.
• The 2020 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations suggests that dobutamine may be used for inotropic support in infants and children with cardiogenic shock 1.

Dosage and Administration

• The dose of dobutamine should be titrated for each individual because there is wide variability in the clinical response to vasoactive drugs.
• A typical starting dose is 2.5-5 mcg/kg/minute, which can be titrated up to 20 mcg/kg/minute as needed.
• Dobutamine should be weaned gradually once hemodynamic stability is achieved, typically by decreasing the dose by 1-2 mcg/kg/minute every 6-12 hours while monitoring for signs of deterioration.

Monitoring and Adjustments

• Echocardiography before and during treatment can help assess cardiac function and guide therapy adjustments.
• Continuous cardiac monitoring is necessary to assess the response to dobutamine and adjust the dose as needed.
• The use of dobutamine in pediatric cardiogenic shock should be guided by the most recent and highest quality evidence, which currently supports its use as a recommended inotropic agent 1.

From the FDA Drug Label

At least in pediatric patients, dobutamine-induced increases in cardiac output and systemic pressure are generally seen, in any given patients, at lower infusion rates than those that cause substantial tachycardia (see Pediatric Use under Precautions). Dobutamine has been shown to increase cardiac output and systemic pressure in pediatric patients of every age group

The role of dobutamine in pediatric cardiogenic shock is to increase cardiac output and systemic pressure. It is effective in pediatric patients of every age group, but its effectiveness and optimal infusion rate may vary from patient to patient, and titration is always necessary 2. In pediatric patients, dobutamine-induced increases in cardiac output and systemic pressure are generally seen at lower infusion rates than those that cause substantial tachycardia 2.

From the Research

Role of Dobutamine in Pediatric Cardiogenic Shock

• Dobutamine is used to increase cardiac output in infants and children with circulatory failure, as it is relatively cardioselective at dosages used in clinical practice, with its main action being on beta 1-adrenergic receptors 3.
• The elimination half-life of dobutamine is about 2 minutes in adults and older children, but no information is available about its pharmacokinetics in neonates and infants 3.
• Adverse effects such as an increase in heart rate usually occur at high dosages of dobutamine 3.

Comparison with Other Inotropes

• Studies comparing dobutamine with milrinone in the treatment of cardiogenic shock have shown no significant difference between the two in terms of primary composite outcome or important secondary outcomes 4, 5.
• Dobutamine and milrinone have similar effectiveness and safety profiles, but with differences in adverse events, such as arrhythmias being more common with dobutamine and hypotension being more common with milrinone 6.
• The choice of dobutamine or milrinone as initial inotrope therapy for cardiogenic shock may depend more on tolerability of adverse events 6.

Clinical Use

• Dobutamine is often used in combination with other vasoactive medications for the treatment of cardiogenic shock 6.
• The use of dobutamine requires careful monitoring of hemodynamic parameters and adverse events, such as arrhythmias and hypotension 4, 6.
• In patients with cardiogenic shock, dobutamine can be used to increase cardiac contractility and improve peripheral perfusion, but its use should be individualized based on patient characteristics and clinical response 7.