The slow, gradual shift from dopamine to norepinephrine as the vasopressor of choice in septic shock has another piece of ammunition – this time a meta-analysis of the observational and randomized trials.
They perform two separate analyses – an analysis of five observational trials and an analysis of six randomized trials. They find heterogeneity and no difference in the observational analysis – and then drop the observational trial responsible for the heterogeneity, and find an RR for mortality of 1.23 favoring norepinephrine. Then, with the randomized trials, they find an RR for mortality of 1.10 favoring norepinephrine. The RR for arrhythmias associated with dopamine use was 2.34 in their pooled analysis.
Of the RCTs, most of the patients came from one trial with 1044 patients and includes four trials with fewer than 50, so it’s not exactly as though this analysis adds a lot of statistical power – but it’s enough to reinforce the trends from each trial.
It is reasonable to suggest that norepinephrine is superior to dopamine – but I would also suggest the magnitude of that difference, given the data we have so far, has only been shown to be small.
“Dopamine versus norepinephrine in the treatment of septic shock: A meta-analysis”
http://www.ncbi.nlm.nih.gov/pubmed/22036860
New NEJM article today showing markedly worse outcomes in septic patients who go into a-fib. Dopamine causes far more a-fib than norepi from data in the trials of this MA. Possibly the reason for the superiority?
New NEJM article today showing markedly worse outcomes in septic patients who go into a-fib. Dopamine causes far more a-fib than norepi from data in the trials of this MA. Possibly the reason for the superiority?
oops, I meant JAMA 2011;306(20):2248
oops, I meant JAMA 2011;306(20):2248
Every study seems to replicate the same thing – increased arrhythmias with dopamine – it could easily be responsible for the main effects on mortality in sepsis.
Every study seems to replicate the same thing – increased arrhythmias with dopamine – it could easily be responsible for the main effects on mortality in sepsis.
As an aside, EMS in the US still primarily uses dopamine as the preferred "ACLS drug". Few carry dobutamine or norepi, although most paramedic services would be able to given they are within our scope.
Is there a pricing difference between the 3 that keeps dopamine at the front, or is this another case of The Tradition of Care?
As an aside, EMS in the US still primarily uses dopamine as the preferred "ACLS drug". Few carry dobutamine or norepi, although most paramedic services would be able to given they are within our scope.
Is there a pricing difference between the 3 that keeps dopamine at the front, or is this another case of The Tradition of Care?
Our ACLS transport trucks/helicopters will continue norepinephrine and dobutamine – as far as starting something, my best guess is that dopamine is preferred because it is not as potentially toxic through a peripheral line. This is not an area of my greatest familiarity.
Our ACLS transport trucks/helicopters will continue norepinephrine and dobutamine – as far as starting something, my best guess is that dopamine is preferred because it is not as potentially toxic through a peripheral line. This is not an area of my greatest familiarity.