What is the recommended protocol for dopamine titration?

Dopamine Titration Protocol

Dopamine should be titrated based on dose-dependent effects, starting at 2-5 mcg/kg/min and increasing in increments of 5-10 mcg/kg/min up to 20-50 mcg/kg/min as needed, with careful monitoring of hemodynamic response. 1, 2

Preparation and Administration

• Dopamine should be administered via infusion pump, preferably a volumetric pump, as gravity-regulated administration is not recommended 2
• Standard preparation options:
  • 400 mg dopamine in 500 mL D5W 3
  • For pediatric patients: use the "rule of 6" (0.6 × body weight in kg = mg diluted to 100 mL; 1 mL/h delivers 0.1 mcg/kg/min) 3
• Administer through a large vein whenever possible (antecubital fossa preferred over dorsum of hand or ankle) to prevent extravasation 2, 4
• Central venous access is preferred for prolonged administration to minimize extravasation risk 4

Dosing Guidelines and Effects

• Initial dose: 2-5 mcg/kg/min in patients likely to respond to modest increases in heart force and renal perfusion 2
• Dose-dependent effects 1, 3:
  • <3 mcg/kg/min: Primarily dopaminergic effects (renal vasodilation)
  • 3-5 mcg/kg/min: Inotropic effects (β-adrenergic)

  • 5 mcg/kg/min: Increase gradually in 5-10 mcg/kg/min increments up to 20-50 mcg/kg/min as needed

  • 10 mcg/kg/min: Predominantly vasopressor effects (α-adrenergic)

• Titration should be individualized based on hemodynamic response and clinical condition 2
• Most adult patients can be maintained on doses <20 mcg/kg/min 2

Monitoring During Titration

• Continuous monitoring of vital signs including blood pressure, heart rate, and ECG is essential 3
• Arterial catheter placement is recommended as soon as practical for patients requiring vasopressors 1
• Monitor for signs of excessive vasoconstriction, especially at doses >20 mcg/kg/min 3
• Assess urine output regularly; reduction in established urine flow may indicate need to decrease dosage 2
• Watch for increasing tachycardia or new dysrhythmias, which may necessitate dose reduction 2

Specific Clinical Scenarios

• For septic shock: Norepinephrine is recommended as first-choice vasopressor; dopamine should be used only in highly selected patients with low risk of tachyarrhythmias or with relative bradycardia 1
• For heart failure with reduced cardiac output: Dopamine may be used at doses of 2-20 μg/kg/min to improve cardiac output 1
• For bradycardia: Dopamine can be administered at 2-10 mcg/kg/min, increasing by 5 mcg/kg/min every 2 minutes 1

Cautions and Adverse Effects

• Infusion rates >20 mcg/kg/min may result in excessive vasoconstriction 3
• Low-dose dopamine (≤3 mcg/kg/min) for renal protection is not recommended 1, 5
• Monitor for extravasation, which can cause severe tissue injury even at low doses 4
• If extravasation occurs, phentolamine (0.1-0.2 mg/kg) can be injected intradermally at the site 3
• When discontinuing the infusion, gradually decrease the dose while expanding blood volume with IV fluids to prevent hypotension 2

Titration Algorithm

1. Begin at 2-5 mcg/kg/min for most patients 2
2. Assess hemodynamic response after 5-10 minutes
3. If inadequate response, increase by 5-10 mcg/kg/min increments 2
4. Continue titration until target blood pressure/perfusion is achieved or maximum dose of 50 mcg/kg/min is reached
5. If doses >50 mcg/kg/min are required, check urine output frequently and consider adding or switching to another vasopressor 2
6. For weaning, gradually decrease dose while monitoring hemodynamic response 2