Dopamine in Clinical Practice
Dopamine should be used cautiously and only in highly selected clinical scenarios, as it is no longer a first-line agent for most indications in the ICU, with norepinephrine preferred for septic shock and dobutamine preferred for inotropic support in heart failure. 1, 2
Dosing Guidelines by Clinical Effect
Dopamine exhibits dose-dependent receptor activity that determines its clinical effects:
- 2-3 mcg/kg/min: Predominantly dopaminergic receptor stimulation with limited effects on diuresis 1, 2
- 3-5 mcg/kg/min: Inotropic effect via β-adrenergic receptor stimulation, increasing myocardial contractility and cardiac output 1, 2, 3
- >5 mcg/kg/min: Combined inotropic and vasopressor effects with α-adrenergic stimulation causing vasoconstriction 1, 2, 3
- >10 mcg/kg/min: Predominantly vasopressor effects 3
The FDA-approved dosing regimen starts at 2-5 mcg/kg/min for patients likely to respond to modest increases in cardiac output, or 5 mcg/kg/min in more seriously ill patients, with gradual increases in 5-10 mcg/kg/min increments up to 20-50 mcg/kg/min as needed. 4
Current Clinical Indications
Septic Shock (Limited Role)
Dopamine is NOT recommended as a first-line vasopressor for septic shock. The Surviving Sepsis Campaign guidelines explicitly state that dopamine should only be used as an alternative to norepinephrine in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia. 1 Norepinephrine is the first-choice vasopressor with strong recommendation. 1
Acute Heart Failure
For acute decompensated heart failure with hypotension (systolic BP <90 mmHg) and signs of peripheral hypoperfusion, dopamine may be considered after preload correction with fluids. 1 However, this carries a Class IIb recommendation (level of evidence C), indicating weak support. 1
Dobutamine is generally preferred over dopamine for inotropic support in heart failure when systolic BP is 90-100 mmHg or higher. 1, 2
Cardiogenic Shock
In cardiogenic shock, norepinephrine has been associated with improved survival at 28 days and fewer arrhythmias compared to dopamine. 1, 2 This represents a critical shift away from dopamine use in this population.
What Dopamine Does NOT Do
Renal Protection is NOT an Indication
Low-dose dopamine should NOT be used for renal protection. This is a strong recommendation (Grade 1A) from the Surviving Sepsis Campaign. 1 Despite decades of use at 2-3 mcg/kg/min for purported renal benefits, well-controlled studies have failed to demonstrate improved renal outcomes or prevention of acute kidney injury. 1, 5, 6, 7 The KDOQI commentary explicitly states that dopamine should be used with caution as a first-line agent given the increased risk of death and arrhythmias in septic shock. 1
Administration and Monitoring
Route and Access
- Central venous access is strongly preferred to prevent extravasation, which can cause severe tissue necrosis even at low doses. 4, 8
- If central access is unavailable, use a large-bore peripheral vein (≥20 gauge, ≥5 cm angiocatheter) in the antecubital fossa, NOT hand or ankle veins. 4, 8
- Intra-osseous access can be used in resource-limited settings when central access is not feasible. 1
- Never administer through umbilical artery catheters. 4
Infusion Requirements
- Use only an infusion pump, preferably volumetric, never gravity-regulated IV apparatus. 4
- Monitor the infusion site continuously for free flow and signs of extravasation. 4, 8
- Do NOT add sodium bicarbonate or alkalinizing substances, as dopamine is inactivated in alkaline solution. 4
Monitoring Parameters
- Continuous ECG monitoring for arrhythmias and heart rate. 2
- Blood pressure monitoring every 5-15 minutes; arterial catheter placement is recommended as soon as practical for all patients requiring vasopressors. 1, 3
- Urine output monitoring—decreasing urine flow in the absence of hypotension warrants dose reduction. 4
- Assess for signs of excessive vasoconstriction: marked decrease in pulse pressure, cold extremities, or rising diastolic pressure disproportionate to systolic pressure. 4
Critical Adverse Effects and Precautions
Cardiovascular Complications
- Tachycardia and arrhythmias are common, particularly at higher doses. 1, 2
- Use with extreme caution when heart rate >100 bpm. 1
- Increased risk of death and arrhythmias compared to norepinephrine in septic shock. 1
- May increase myocardial oxygen demand, potentially worsening ischemia. 1, 2
Non-Cardiovascular Toxicity
- Worsens splanchnic oxygenation and impairs GI function. 7
- Impairs endocrine and immunologic systems. 7
- Blunts ventilatory drive. 7
- May aggravate lactic acidosis. 1
Extravasation Risk
Extravasation can cause severe tissue necrosis and sloughing even at low doses (<3 mcg/kg/min). 4, 8 If extravasation occurs, administer phentolamine 0.1-0.2 mg/kg into the affected area. 3
Weaning and Discontinuation
When discontinuing dopamine, gradually decrease the dose while expanding blood volume with IV fluids to prevent marked hypotension. 4 Abrupt cessation can lead to hemodynamic collapse.
Pharmacokinetic Variability
A critical caveat: Despite weight-based dosing, plasma dopamine concentrations show 10- to 75-fold interindividual variability in healthy subjects. 9 This means identical weight-based doses produce vastly different blood levels and clinical effects between patients, necessitating careful titration to clinical endpoints rather than relying on dose alone. 9
Bottom Line Algorithm
- For septic shock: Use norepinephrine first-line; reserve dopamine only for patients with bradycardia and low arrhythmia risk. 1
- For acute heart failure with hypotension: Consider dopamine only if SBP <90 mmHg after fluid resuscitation; otherwise use dobutamine. 1, 2
- For cardiogenic shock: Prefer norepinephrine over dopamine due to mortality benefit. 1, 2
- Never use for renal protection. 1
- Always use central access when possible and continuous infusion pump. 4
- Monitor continuously for arrhythmias, extravasation, and end-organ perfusion. 2, 4