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July 1, 2014 by dailybolusoflr

Medical Minute from Darren Mareiniss, MD JD

Vasopressors in shock: SOAP II Study Data and the 2012 Surviving Sepsis Guidelines

SOAP II Study Comparing Norepinephrine versus Dopamine for All Causes of Sepsis
Design: Multicenter, randomized trial where patients with shock received either dopamine or norepinephrine as first line agents to maintain BP.  When BP could not be maintained on either 20 ug/kg/min dopamine or .19 ug/kg/min Norepinephrine, open-label norepinephrine, vasopressin or epinephrine was used. 
Results: 1679 patients with 858 in the dopamine group and 821 in the norepinephrine group.  There was no mortality difference at 28 days (52.5% in dopamine group and 48.5% in the norepinephrine group).  More arrhythmia in the dopamine group – 207 (24.1%) versus 102 (12.4%), P <0.001.  A subgroup analysis showed that dopamine resulted in a higher 28 day mortality in patients with cardiogenic shock, P=0.03.
Conclusion: Dopamine increased arrhythmia in patients compared to norepinephrine.  With respect to cardiogenic shock, dopamine had significantly increased 28 day mortality.
Meta-analysis by De Backer et al – shows a modest increased relative risk of mortality for use of Dopamine versus Norepinephrine.  RR of death 1.12; 95% CI, 1.01-1.2; P=0.035. 
Bottom Line– Dopamine appears to be associated with increased mortality and arrhythmia when used as a first line agent in shock.  In particular, dopamine appears to increase mortality in cardiogenic shock and should not be used for this pathology
2012 Surviving Sepsis Guidelines for Vasopressors  

  •  After 30 ml/kg of crystalloid – use vasopressors to keep MAP > 65 mm Hg
  •  First line agent – Norepinephrine
  • Second line – add Vasopressin at .03 u/min – do not use .04 u/min unless for salvage
  •  Second line – may add or substitute Epinephrine for Norepinephrine
  •  Third line agents – Dopamine is only recommended for select patients at low risk for tachyarrhythmia and absolute or relative bradycardia
  • Fourth line agent – Phenylephrine is not recommend in septic shock except – However, can be given when: (1) cardiac output is known to be high and BP is low; (2) Norepinephrine is associated with serious arrhythmia; or (3) as salvage therapy when inotrope/vasopressors and low dose Vasopressin has failed. 

References
  1. DeDe Backer D, Biston P, Devriendt J et al. Comparison of Dopamine and Norepinephrine in the Treatment of Shock. N Engl J Med. 2010;362(9):779-789.
  2. De Backer D, Aldecoa C, Njimi H et al. Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis. Crit Care Med 2012;40(3):725-730.
  3. Dellinger RP, Levy MM, Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. Intensive Care Med 2013; 39:165-228.

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