Vasopressors in the ED

Dopamine: ONE LINER: POOR MAN’S NOREPI - Mechanism: Dopa/β/⍺ agonism - Dose: Dose dependent effects o Low Doses: 2 – 5 mcg/kg/minàDopa agonismo Mid Doses: 5 – 10 mcg/kg/minàβ agonism o High Doses: 10 – 20 mcg/kg/minà⍺ agonism - Indication: Bradycardia OR Hypotension. If both, use epi - Good/Bad: (-) Arrhythmias; (-) More adverse events compared to norepi.

Dopamine Use in Intensive Care: Are We Ready to Turn it Down?

Dopamine is still frequently used as a first line vasopressor agent in hypotensive patients, when physicians are afraid of noradrenaline and believe that dopamine, with its β and α, inotrope and vasopressor effects, may be helpful. Evidence exists that it does not offer protection from renal failure, even if at low doses (0, 3–5 mcg/Kg/min) it may exert its effects on D1 and D2 receptors resulting in natriuresis and renal vasodilation, augmentation in renal blood flow, and diuresis.

Reassessment of Dobutamine, Dopamine, and Milrinone in the Management of Acute Heart Failure Syndromes

Randomized controlled trials failed to show benefits with current medications and suggested that acute, intermittent, or continuous use of inodilator infusions may increase morbidity and mortality in patients with AHFS. Their use should be restricted to patients who are hypotensive as a result of low cardiac output despite a high left ventricular filling pressure.

Vasopressors for Septic Shock (from the Surviving Sepsis Guidelines)

Dopamine is suggested to not be used as an alternative to norepinephrine in septic shock, except in highly selected patients such as those with inappropriately low heart rates (absolute or relative bradycardia) who are at low risk for tachyarrhythmias (Grade 2C). Dopamine is recommended to not be used in low doses in a so-called renal-protective strategy (Grade 1A).

Why should intravenous dopamine infusion be closely monitored in cardiogenic shock?

The aim of using dopamine in cardio genic shock is to improve the perfusion pressure so that there is adequate tissue perfusion without increasing the myocardial oxygen demand( requirement of blood flow). Inotropes that increase heart rate and systemic vascular resistance typically increase the work of the heart.Dopamine at lower doses would decrease peripheral resistance and at higher doses increases peripheral resistance.