From the Guidelines
Dopamine is not recommended as a first-line vasopressor for septic shock management, and norepinephrine should be used as the initial vasopressor. According to the Surviving Sepsis Campaign guidelines 1, norepinephrine is the preferred initial vasopressor, typically started at 0.05-0.1 mcg/kg/min and titrated to maintain a mean arterial pressure (MAP) of ≥65 mmHg. Dopamine has fallen out of favor due to its association with more arrhythmias and potentially higher mortality compared to norepinephrine, as shown in a meta-analysis of five randomized trials (n = 1,993 patients with septic shock) comparing norepinephrine to dopamine 1.
Some key points to consider when using vasopressors in septic shock management include:
- Norepinephrine is the first-choice vasopressor, with a strong recommendation and moderate quality of evidence 1
- Dopamine may be used as an alternative vasopressor agent to norepinephrine only in highly selected patients, such as those with low risk of tachyarrhythmias and absolute or relative bradycardia, with a weak recommendation and low quality of evidence 1
- Vasopressin (0.01-0.04 units/min) or epinephrine may be added as second-line agents if norepinephrine is insufficient 1
- Adequate fluid resuscitation should always precede or accompany vasopressor therapy, and underlying causes of sepsis must be addressed with appropriate antimicrobial therapy and source control 1
It's also important to note that dopamine works by stimulating dopaminergic, beta-adrenergic, and alpha-adrenergic receptors in a dose-dependent manner, with predominant vasopressor effects at higher doses. However, the higher dose range of dopamine (5-20 mcg/kg/min) increases the risk of tachyarrhythmias. In current practice, dobutamine may be used to treat septic shock patients with myocardial dysfunction, but it has raised serious questions regarding its safety in the treatment of septic shock 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 Reports indicate that the shorter the time between onset of signs and symptoms and initiation of therapy with volume restoration and dopamine, the better the prognosis
Dopamine for Septic Shock:
- Dopamine is indicated for the correction of hemodynamic imbalances present in shock due to endotoxic septicemia.
- The prognosis is better when dopamine is administered before extreme deterioration of physiological parameters.
- The dosage of dopamine should be adjusted according to the patient's response, with careful monitoring of urine flow, cardiac output, blood pressure, and distribution of peripheral perfusion 2.
- A suggested regimen for dopamine administration in septic shock includes starting with doses of 2 to 5 mcg/kg/min and increasing gradually as needed, up to a rate of 20 to 50 mcg/kg/min 2.
From the Research
Dopamine for Septic Shock
- Dopamine is recommended as a first-line vasopressor agent in septic shock, along with norepinephrine, according to international guidelines 3.
- However, studies have shown that norepinephrine is associated with decreased all-cause mortality compared to dopamine in patients with septic shock, with a corresponding absolute risk reduction of 11% and number needed to treat of 9 3, 4.
- Norepinephrine has also been shown to have a lower risk of major adverse events and cardiac arrhythmias compared to dopamine 3, 4.
- A systematic review of randomized clinical trials found that norepinephrine was superior to dopamine in terms of in-hospital or 28-day mortality, with a pooled risk ratio of 0.91 (95% CI 0.83 to 0.99; P = .028) 4.
- A retrospective cohort study found that patients receiving dopamine as initial vasopressor experienced greater hospital mortality compared to those receiving norepinephrine, with an odds ratio of 1.08 (95% CI 1.02-1.14) 5.
- Another study found that fixed-dose vasopressin was similar to titrated dopamine and norepinephrine in terms of early blood pressure effects in patients with septic shock 6.
- A review of the literature found that dopamine was associated with increased arrhythmic events and higher 30-day mortality compared to norepinephrine in patients with septic shock 7.