Dopamine Dosing in Critically Ill Adults
Dopamine should NOT be used as a first-line vasopressor in critically ill adults with cardiovascular or renal disease—norepinephrine is the mandatory first choice, and dopamine should only be considered in highly selected patients with low risk of tachyarrhythmias and absolute or relative bradycardia. 1, 2
Why Dopamine is NOT Recommended
The Surviving Sepsis Campaign explicitly recommends against dopamine as first-line therapy (Grade 2C), reserving it only for highly selected patients with bradycardia or very low arrhythmia risk. 1, 2
Dopamine increases 28-day mortality by 11% absolute risk compared to norepinephrine (number needed to harm = 9 patients). 2
Dopamine causes significantly more cardiac arrhythmias: 53% increased risk of supraventricular arrhythmias (RR 0.47 for norepinephrine vs dopamine) and 65% increased risk of ventricular arrhythmias (RR 0.35). 2
Low-dose dopamine for "renal protection" is explicitly contraindicated (Grade 1A)—it provides no clinically significant protection from renal dysfunction and should never be used for this indication. 1, 3
If Dopamine Must Be Used (Rare Circumstances Only)
Initial Dosing Protocol
Start at 2-5 mcg/kg/min in patients likely to respond to modest increments of heart force and renal perfusion. 4
In more seriously ill patients, start at 5 mcg/kg/min and increase gradually using 5-10 mcg/kg/min increments, up to 20-50 mcg/kg/min as needed. 4
The average effective dose in clinical studies was 17.2 mcg/kg/min. 5
Administration Requirements
Administer only through central venous access using an infusion pump (preferably volumetric)—never use gravity-regulated IV apparatus. 4
Avoid umbilical artery catheters for administration. 4
Monitor continuously for extravasation, which causes tissue necrosis and sloughing. 4
Titration Targets and Limits
Titrate to achieve mean arterial pressure of 65-70 mmHg and urine output >40 mL/hr. 5
Stop escalation if heart rate exceeds 120-125 beats/min or if dangerous arrhythmias develop—these are absolute limiting endpoints. 4, 5
More than 50% of patients are adequately maintained on doses <20 mcg/kg/min. 4
Doses >50 mcg/kg/min require frequent urine output monitoring—if urine flow decreases without hypotension, reduce the dose immediately. 4
Critical Monitoring Parameters
Watch for disproportionate rise in diastolic pressure (marked decrease in pulse pressure)—this indicates predominant vasoconstrictor activity and requires immediate dose reduction. 4
Monitor for new dysrhythmias, increasing tachycardia, or diminishing urine flow—all are reasons to decrease or temporarily suspend dopamine. 4
The Correct First-Line Approach
Instead of dopamine, initiate norepinephrine at 0.1-0.5 mcg/kg/min through central venous access, targeting MAP ≥65 mmHg after administering at least 30 mL/kg crystalloid resuscitation. 2
Escalation Algorithm When Norepinephrine Alone is Insufficient
Add vasopressin at 0.03 units/minute (never exceed 0.03-0.04 units/minute for routine use) to raise MAP or decrease norepinephrine requirements. 1, 2
If still inadequate, add epinephrine at 0.05-2 mcg/kg/min as the third vasopressor agent. 2
For persistent hypoperfusion despite adequate MAP, add dobutamine 2.5-20 mcg/kg/min to address cardiac output rather than vascular tone. 1, 2
Common Pitfalls to Avoid
Never use dopamine for "renal protection"—this practice is harmful, worsening splanchnic oxygenation, impairing GI function, and blunting ventilatory drive without providing renal benefit. 1, 3
Do not combine dopamine with epinephrine due to additive adverse effects and dramatically increased arrhythmia risk. 2
In patients with acute myocardial ischemia, dopamine worsens myocardial metabolism by increasing oxygen extraction and lactate production, making it potentially harmful to ischemic myocardium. 5
Avoid using dopamine in patients with atrial fibrillation or any tachyarrhythmia, as it significantly increases arrhythmia risk. 2, 6