What are the implications of administering dopamine through a peripheral intravenous (IV) line?

From the Guidelines

Dopamine should be administered through a peripheral IV with caution, starting at a dose of 2-5 mcg/kg/min and titrating up to 20 mcg/kg/min as needed, while closely monitoring for signs of extravasation and using an infusion pump for accurate delivery 1.

Key Considerations

• The use of dopamine in patients with shock should be done with caution, as it has been associated with more adverse events and an increased risk of death in certain patient populations 1.
• The recommended concentration for peripheral administration is 1600 mcg/mL or less, typically prepared as 400-1600 mcg/mL.
• Dopamine works by stimulating different receptors depending on the dose:
  • At low doses (1-5 mcg/kg/min), it primarily affects dopaminergic receptors, improving renal blood flow.
  • At moderate doses (5-10 mcg/kg/min), it stimulates beta-adrenergic receptors, increasing cardiac output.
  • At higher doses (>10 mcg/kg/min), it activates alpha-adrenergic receptors, causing vasoconstriction.

Administration and Monitoring

• It's essential to use an infusion pump for accurate delivery and to monitor the IV site frequently for signs of extravasation, which can cause tissue necrosis.
• If extravasation occurs, stop the infusion immediately and consider phentolamine infiltration (5-10 mg diluted in 10-15 mL of normal saline) into the affected area.
• For prolonged therapy or higher doses, central venous access is preferred to minimize extravasation risk.

Clinical Context

• The use of dopamine in patients with acute kidney injury (AKI) is not recommended for prevention or treatment, as it has not been shown to be effective and may even be harmful 1.
• In patients with shock, fluid resuscitation is typically insufficient to fully restore blood pressure to normal levels, and the use of vasopressors, such as dopamine, may be necessary to support blood pressure and prevent AKI.

From the FDA Drug Label

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. Large veins of the antecubital fossa are preferred to veins of the dorsum of the hand or ankle Administration into an umbilical arterial catheter is not recommended.

Dopamine should be administered through a peripheral IV in a large vein, preferably in the antecubital fossa, to minimize the risk of extravasation and necrosis 2, 2.

• Key considerations for peripheral IV administration of dopamine include:
  • Using a large vein to reduce the risk of infiltration and extravasation
  • Avoiding administration into an umbilical arterial catheter
  • Monitoring the infusion site for free flow and signs of complications
• Precautions should be taken to prevent hypokalemia, fluid overload, and electrolyte imbalances during dopamine infusion 2, 2.

From the Research

Administration of Dopamine through Peripheral IV

• Dopamine is frequently administered in the ICU to critically-ill patients, but its widespread use should be reassessed 3.
• Low-dose dopamine therapy can cause tissue ischemia or necrosis secondary to vasospasm and extravasation, even when infused peripherally 4.
• Administration of dopamine via peripheral intravenous access is feasible and safe, with extravasation occurring in 2% of patients without any tissue injury following treatment 5.

Safety Precautions for Peripheral Dopamine Administration

• A central intravenous access should be placed for dopamine infusion whenever possible 4.
• If central access is not feasible, dopamine should be infused only peripherally through a long intravenous catheter into a large vein 4.
• The infusion site should be inspected frequently for early detection of extravasation, and changed to a central or a peripherally inserted central catheter as soon as possible 4.

Comparison with Other Vasopressors

• Norepinephrine is more efficacious in fluid resuscitated septic shock patients to restore blood pressure than dopamine, without jeopardizing the renal function 3.
• The combination of norepinephrine-dobutamine appears to be a more reliable and safer strategy than epinephrine in cardiogenic shock patients 6.
• Peripheral administration of vasopressor medications, including dopamine, is a feasible and safe alternative to central venous catheters, with extravasation occurring in 3.4% of patients 7.