Dopamine – Not so Dope

Generally, dopamine (DA) is a dirty, dirty drug. It hits a variety of receptors at different dose ranges making it difficult to determine what exactly it’s doing for your patient. But let’s examine the literature.

In the pediatric population, epinephrine (epi) has been compared to DA in two RCTs with fluid refractory shock. One study showed that epi was associated with a lower risk of mortality at day 28 and increased risk of hospital acquired infection compared to DA. The second study showed that epi was associated with a more rapid resolution of shock and more organ failure-free days among survivors compared to DA.

Norepinephrine (NE) is understudied in kids with septic shock. Evidence from a systematic review and meta-analysis of adult trials shows a survival benefit and lower incidence of arrhythmias with NE compared to DA. The review also reports no difference in mortality with epi vs. NE.

In a survey of the panel members for the Surviving Sepsis Guidelines, epi and NE were equally used as first-line vasoactive meds. Epi was the preference for treatment of myocardial dysfunction and low cardiac output, and NE was preferred for increasing low systemic vascular resistance. Thus, either drug is recommended for use as the initial vasoactive agent with a recommendation for echocardiogram or other advanced monitoring to help drive vasoactive support.

Historically, DA has often been initiated as a drug of choice for use when only peripheral access is available. Any vasoactive agent may be initiated through peripheral IVs or IOs if central access has not been obtained – although, it should be obtained as soon as possible! Panelists for the Surviving Sepsis Guidelines preferred epi or DA over NE for peripheral infusions. In my practice, if I am confident that I have a good peripheral IV, I will sometimes administer NE through that IV while working on central access.