pro - pcics · “norepinephrine and dopamine centrally administered are the initial vasopressors...
TRANSCRIPT
Pro:
Dopamine is Evil and Should be
Banned from the Face of the Earth
Martina Steurer, MD MAS
December 2018
No disclosures
Beta-3,4-Dihydroxypenylethylamine
Barger G, Dale HH: Chemical structure and sympathomimetic action of amines.
J Physiol 1910; 41:19–59
Dopamine
D1 and D2 Beta-1 Alpha-1
Renal and splanchnic
perfusion
Cardiac output via
chronotropy and inotropy
Increase of
peripheral resistance
Hemodynamic Effects of Dopamine
Dose
Receptor
Effect
< 5 mcg/kg/min 5-15 mcg/kg/min >15 mcg/kg/min
The myth of renal protection
When compared to dobutamine, there was no difference in renal function or urine output in
142 children after heart surgeryWenstone R, Campbell JM, Booker PD, McKay R. Renal function after cardiopulmonary bypass in children:
comparison of dopamine with dobutamine. Br J Anaesth. 1991.
Two meta analyses do not show protection from renal dysfunction or improve in outcome
variables Kellum JA, M Decker J. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med. 2001.
Marik PE. Low-dose dopamine: a systemic review. Int Care Med. 2002.
The myth of renal protection
Random effects model of weighted mean difference (95% confidence interval) of the change in
serum creatinine in patients randomized to low- dose dopamine compared to control
Marik PE. Low-dose dopamine: a systemic review. Int Care Med. 2002.
Maybe even harmful to the gut
Dopamine may cause uncompensated increase in splanchnic oxygen requirements in septic
patientsMarik PE and Mohedin M. The contrasting effects of dopamine and norepinephrine on systemic and splanchnic
oxygen utilization in hyperdynamic sepsis. JAMA. 1994.
Dopamine does not increase splanchnic blood flow in the critically illMaynard ND, Bihari DJ, Dalton RN, Smithies MN, Mason RC. Increasing splanchnic blood flow in the critically III.
Chest. 1995.
Dopamine decreases gastric mucosal blood flow in septic patientsNevière R, Mathieu D, Chagnon JL, Lebleu N, Wattel F. The contrasting effects of dobutamine and dopamine on
gastric mucosal perfusion in septic patients. Am J Respir Crit Care Med. 1996.
D1 and D2 Beta-1 Alpha-1
Renal and splanchnic
perfusion
Cardiac output via
chronotropy and inotropy
Increase of
peripheral resistance
Hemodynamic Effects of Dopamine
Dose
Receptor
Effect
< 5 mcg/kg/min 5-15 mcg/kg/min >15 mcg/kg/min
Dobutamine NorepinephrineEpinephrine
Vasopressin
Milrinone
2008
2017
Surviving Sepsis Campaign
“Norepinephrine and dopamine centrally administered are the initial vasopressors of
choice”
“We recommend norepinephrine as the first- choice vasopressor“
Dopamine for sepsis or septic shock
2008
2017
Surviving Sepsis Campaign
“Norepinephrine and dopamine centrally administered are the initial vasopressors of
choice”
“We recommend norepinephrine as the first- choice vasopressor“
Dopamine for sepsis or septic shock
2008
2017
Surviving Sepsis Campaign
“Norepinephrine and dopamine centrally administered are the initial vasopressors of
choice”
“We recommend norepinephrine as the first- choice vasopressor“
De Backer D, Aldecoa C, Njimi H, Vincent J-L. Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis. Crit Care Med 2012.
Dopamine for sepsis or septic shock
Dopamine for sepsis or septic shock
Epinephrine is more effective than dopamine in achieving resolution of fluid-
refractory hypotensive cold shock within the first hour of resuscitation and
improving organ functions.
Pediatric Evidence
Nov 2016
Other diabolic effects of Dopamine
Respiratory system Immune system Pituitary glandCNS
Other diabolic effects of Dopamine
Respiratory effects
Reduces ventilatory response to hypoxia and
hypercapniaSabol SJ, Ward DS. Effect of dopamine on hypoxic-hypercapnic
interaction in humans. Anesthesia & Analgesia. 1987.
Slows respiratory rateWard DS, Bellville JW. Effect of intravenous dopamine on
hypercapnic ventilatory response in humans. J Appl Physiol Respir
Environ Exerc Physiol. 1983.
Glomus caroticum
Common carotid artery
Other diabolic effects of Dopamine
Immunological effects
Other diabolic effects of Dopamine
Immunological effects
D1 and D2 receptors
T-cell B-cell
Santambrogio L, Lipartiti M, Bruni A, Dal Toso R. Dopamine receptors on human T and B-lymphocytes. J Neuroimmunol. 1993.
Kouassi E, Li YS, Boukhris W, Millet I, Revillard JP. Opposite effects of catecholamines dopamine and norepinephrine on murine polyclonal B-cell
activation. Immunopharmacology. 1988
Devins SS, Miller A, Herndon BL, O’Toole L, Reisz G. Effects of dopamine on T-lymphocyte proliferative responses and serum prolactin concentrations
in critically ill patients. 1992.
Cytokine secretion Proliferation Ig secretion
Other diabolic effects of Dopamine
CNS
Other diabolic effects of Dopamine
Reward
Schizophrenia
Parkinson
Other diabolic effects of Dopamine
CNS
Dopamine administration is associated with delirium in critically ill patients and in
patients after coronary artery bypass surgery - two retrospective observational studies
Sommer BR, Wise LC, Kraemer HC. Is dopamine administration possibly a risk factor for delirium? Crit Care Med.
2002.
Seyhan Yilmaz MD P, MD EA, Adem Ilkay Diken MD P, Adnan Yalcinkaya MD P, MD MEE, Kerim Cagli MD P.
Dopamine Administration is a Risk Factor for Delirium in Patients Undergoing Coronary Artery Bypass Surgery.
Heart, Lung and Circulation. 2016.
Blood brain barrier
Other diabolic effects of Dopamine
Pituitary gland and endocrine effects
Other diabolic effects of Dopamine
Pituitary gland and endocrine effects
ProlactinTSH
Growth Hormone
Anterior pituitary lobePosterior pituitary lobe
Dopamine
T-cell proliferation
Other diabolic effects of Dopamine
Pituitary gland and endocrine effects
Suppressed pituitary function in 33 infants and children treated with dopamine
after cardiothoracic surgery for congenital heart diseaseVan den Berghe G, de Zegher F, Lauwers P. Dopamine suppresses pituitary function in infants and
children. Crit Care Med. 1994.
Review on dopamine and anterior pituitary functionVan den Berghe G, de Zegher F. Anterior pituitary function during critical illness and dopamine treatment.
Crit Care Med. 1996.
Dopamine is evil
Norepinephrine
Epinephrine
Thank you!