Should You Add Dopamine to Norepinephrine and Vasopressin in Severe Shock?
No, you should not add dopamine to a patient already receiving norepinephrine and vasopressin—instead, add epinephrine as your third vasopressor agent. 1, 2
Why Dopamine Should Be Avoided in This Scenario
The Surviving Sepsis Campaign and COVID-19 guidelines explicitly recommend against using dopamine when norepinephrine is available, with a strong recommendation. 1 This recommendation is based on compelling evidence:
Dopamine is associated with significantly higher mortality compared to norepinephrine (RR 0.91; 95% CI 0.83-0.99), meaning norepinephrine reduces death by approximately 9% compared to dopamine 1
Dopamine causes dramatically more cardiac arrhythmias: supraventricular arrhythmias occur in 22.9% with dopamine versus 8.2% with norepinephrine (RR 0.47), and ventricular arrhythmias in 3.9% versus 1.5% (RR 0.35) 1, 3, 4
In the landmark 2010 NEJM trial of 1,679 patients, dopamine was associated with 24.1% arrhythmic events versus 12.4% with norepinephrine (P<0.001) 3
Dopamine should only be considered in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia—not in patients already on two vasopressors 1, 2
The Correct Escalation Algorithm
When norepinephrine plus vasopressin fail to achieve target MAP of 65 mmHg, follow this evidence-based sequence:
Third-Line Agent: Add Epinephrine
Add epinephrine at 0.05-2 mcg/kg/min (or 0.1-0.5 mcg/kg/min) when norepinephrine plus vasopressin are insufficient 1, 2
Epinephrine is recommended as the second or third agent to be added to norepinephrine when additional vasopressor support is needed (Grade 2B recommendation) 1
This is superior to escalating vasopressin beyond 0.03-0.04 units/min, which should be reserved only for salvage therapy due to risks of cardiac, digital, and splanchnic ischemia 1, 2
Consider Inotropic Support
If persistent hypoperfusion exists despite adequate vasopressor support, particularly with evidence of myocardial dysfunction, add dobutamine up to 20 mcg/kg/min rather than adding more vasopressors 1, 2
Start dobutamine at 2.5 mcg/kg/min and double every 15 minutes according to response, with dose titration limited by tachycardia, arrhythmias, or ischemia 5
Corticosteroids for Refractory Shock
- For refractory shock despite multiple vasopressors, add hydrocortisone 200 mg/day IV for shock reversal 1, 2
Critical Context: Your Patient's Vasopressor Doses Matter
The appropriateness of adding any third agent depends on your current vasopressor doses:
If norepinephrine is ≥15 mcg/min (or ≥0.25 mcg/kg/min), you should have already added vasopressin—which you have 2
Vasopressin should be at 0.03 units/min (maximum 0.03-0.04 units/min) 1, 2, 6
If both are at appropriate doses and MAP remains <65 mmHg, epinephrine is your next agent, not dopamine 2
Why This Matters Clinically
Adding dopamine to an already complex vasopressor regimen would:
Increase arrhythmia risk by 2-3 fold when the patient is already critically ill 1, 3, 4
Potentially worsen mortality based on comparative data showing dopamine's inferiority to norepinephrine 1, 3, 7
Violate current guideline recommendations that explicitly state dopamine should not be used when norepinephrine is available 1, 2
The 2020 COVID-19 guidelines specifically state: "For adults with COVID-19 and shock, we recommend against using dopamine if norepinephrine is available" (Strong recommendation) 1—and this principle applies to all forms of distributive shock, not just COVID-19.
Common Pitfalls to Avoid
Never use dopamine for "renal protection"—this is strongly discouraged and has no benefit 2
Do not escalate vasopressin above 0.03-0.04 units/min to try to avoid adding a third agent—higher doses cause ischemic complications 1, 2
Do not add phenylephrine as a third agent—it is not recommended except in specific circumstances like norepinephrine-induced arrhythmias or documented high cardiac output with persistent hypotension 1, 2
Ensure adequate fluid resuscitation (minimum 30 mL/kg crystalloid) has been achieved before escalating vasopressors further 1, 2