Pediatric Surviving Sepsis and PALS Guidelines recommend epinephrine and norepinephrine over dopamine in septic shock. BUT WHY!?
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.
- Epinephrine and norepinephrine are preferred over dopamine in septic shock.
- Think about epinephrine for myocardial dysfunction and low cardiac output.
- Think about norepinephrine for increasing systemic vascular resistance.
- Epinephrine may be preferred over norepinephrine if only peripheral access is available.
- Weiss SL, Peters MJ, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children, Pediatric Critical Care Medicine: February 2020 – Volume 21 – Issue 2 – p e52-e106 doi: 10.1097/PCC.0000000000002198). PMID: 32030529.
- Topjian AA, Raymond TT, et al.; Pediatric Basic and Advanced Life Support Collaborators. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S469-S523. doi: 10.1161/CIR.0000000000000901. Epub 2020 Oct 21. PMID: 33081526.
- Ventura AM, Shieh HH, et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med. 2015 Nov;43(11):2292-302. doi: 10.1097/CCM.0000000000001260. PMID: 26323041.
- Ramaswamy KN, Singhi S, et al. Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock. Pediatr Crit Care Med. 2016 Nov;17(11):e502-e512. doi: 10.1097/PCC.0000000000000954. PMID: 27673385.
- Avni T, Lador A, et al. Vasopressors for the Treatment of Septic Shock: Systematic Review and Meta-Analysis. PLoS One. 2015 Aug 3;10(8):e0129305. doi: 10.1371/journal.pone.0129305. PMID: 26237037.