Dopamine and Sepsis

[BurgMedic]

Hey all,

I am new to the forums. I have been a medic for 2 years now. I had an interesting call the other day and I wanted to run it by some experienced members here to get some feedback.

My protocols allow Epi and Dopa drips for hypotensive crisis. I had a patient the other day in severe septic shock, with a 25 min transport time. Absent radial pulses, weak and rapid central pulses, and BP so low it was undetectable. Patient was a difficult IV stick but I managed to get a 22g in her forearm, and started a liter of fluid. The vein would hold no larger then the 22g.

Checked for an EJ and due to adipose in the neck region, could not find a suitable site. So, I was forced to run with one IV site and one liter bag at a time. The fluids were not touching her pressure and due to the transport time, I started considering a pressor. Her heart rate was 125 and I hesitated to start the Dopamine.

Long story short, I withheld Dopamine. Upon arrival to the ER, while briefing the MD, I happened to mention my consideration of Dopamine. The MD promptly snapped at me for even considering Dopamine in septic shock.

Having been taught my whole career that Dopamine was a viable choice for septic shock, I was perplexed at his reaction. I understand that Levo is in vogue currently as the drug of choice for septic shock refractory to fluids, but seeing as most services don't carry it, I fail to see how Dopamine should not be considered.

Any feedback?

 

[Underoath87]

Beats me. We're to try 1-2 L of fluid, then dopamine, then an epi drip.
Next time you see this doc, ask him what he has against dopamine.

 

[chaz90]

The beta effects are frowned upon for treatment of patients who are hypotensive and tachycardic. Basically, these elderly, volume depleted patients need primarily fluid, and secondarily alpha antagonism. Opinions will vary on whether dopamine should ever "be considered" in a case like you mentioned, but it's very rarely first line for distributive shock. Despite what we're taught about the "primarily alpha effects" that come about with higher doses of dopamine, tachycardia is still going to result.


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[BurgMedic]

The beta effects are frowned upon for treatment of patients who are hypotensive and tachycardic. Basically, these elderly, volume depleted patients need primarily fluid, and secondarily alpha antagonism. Opinions will vary on whether dopamine should ever "be considered" in a case like you mentioned, but it's very rarely first line for distributive shock. Despite what we're taught about the "primarily alpha effects" that come about with higher doses of dopamine, tachycardia is still going to result.


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While I totally get what you are saying, do we not treat another type of distributive shock with a very similar pathophysiology with an even more potent beta agonist? Medicine widely accepts treating anaphylaxis with Epi, even though these patients will be hypotensive and tachycardic, and Epi will almost certainly stimulate more tachycardia. So, why is this considered safe and effective, but Dopamine (a very similar medication to Epi in mechanism and effect) is considered dangerous in treating septic shock (a very similar disease process to vasodilated anaphylactic shock)?

 

[Brandon O]

Just not so popular these days. More tendency to provoke tachyarrythmias than most and increases myocardial demand quite a bit. Promotes diuresis, not a great thing in sepsis. Not a terribly predictable dose-response curve. Nowadays it's usually norepi then pick your poison.

 

[Tigger]

While I totally get what you are saying, do we not treat another type of distributive shock with a very similar pathophysiology with an even more potent beta agonist? Medicine widely accepts treating anaphylaxis with Epi, even though these patients will be hypotensive and tachycardic, and Epi will almost certainly stimulate more tachycardia. So, why is this considered safe and effective, but Dopamine (a very similar medication to Epi in mechanism and effect) is considered dangerous in treating septic shock (a very similar disease process to vasodilated anaphylactic shock)?

It is apparently the Society of Critical Care Medicine (the authors of Surviving Sepsis) that epinephrine is the second choice agent for hypotension in sepsis.
http://www.survivingsepsis.org/Guidelines/Documents/Hemodynamic Support Table.pdf

There is some research showing worse outcomes with dopamine as well.
http://www.ncbi.nlm.nih.gov/pubmed/22036860

 

[Summit]

1 get IO
2 dopamine undesirable in sepsis http://www.uptodate.com/contents/us...otropes/abstract/11,28,48,59-62?utdPopup=true

 

[Carlos Danger]

Your protocols should specify which agent to use in hypotension, depending on the suspected cause. But assuming they do not, that ED doc was being a prick getting all worked up over your choice of dopamine. He could have used it as a teaching moment but it sounds like he didn't. It wasn't that long ago that dopamine was what pretty everyone - especially ED docs - reached for in pretty much any case of severe hypotension.

I don't know that dopamine causes any more tachycardia or increases Mv02 any more than epinephrine - it is probably highly dose dependent - but it is a pretty dirty drug with all sorts of side effects. Norepi was in vogue last month, this week it's epinephrine, apparently. It seems that all guidelines related to resuscitation change significantly every few years when we find out that the thing we thought was the best since sliced bread isn't really the thing we should be doing at all.

If you had used dopamine, it seems unlikely that it would have caused any harm during a short transport. But now you know better.

 

[Tigger]

Your protocols should specify which agent to use in hypotension, depending on the suspected cause. But assuming they do not, that ED doc was being a prick getting all worked up over your choice of dopamine. He could have used it as a teaching moment but it sounds like he didn't. It wasn't that long ago that dopamine was what pretty everyone - especially ED docs - reached for in pretty much any case of severe hypotension.

I don't know that dopamine causes any more tachycardia or increases Mv02 any more than epinephrine - it is probably highly dose dependent - but it is a pretty dirty drug with all sorts of side effects. Norepi was in vogue last month, this week it's epinephrine, apparently. It seems that all guidelines related to resuscitation change significantly every few years when we find out that the thing we thought was the best since sliced bread isn't really the thing we should be doing at all.

If you had used dopamine, it seems unlikely that it would have caused any harm during a short transport. But now you know better.

I think norepi is still the "preferred" pressor in sepsis, but if that's not cutting it maybe consider using epi along with.

 

[Summit]

Norepi... then Vaso... then Epi

 

[SeeNoMore]

I would certainly use Epi over Dopamine in this case (with no other options and continued hypotension s/p fluid) but either way I think you are correct to consider the addition of a vasopressor rather than continued hypoperfusion.

 

[NYBLS]

Why not use an IO? A humeral head IO equates to around an 18g PIV.

 

[SeeNoMore]

I got the impression the OP did not have an IO?

 

[Handsome Robb]

Another thing to consider is dopamine through a 22g PIV, especially one that has potential to easily infiltrate isn't the greatest of ideas.

 

[Handsome Robb]

Plus everything else that everyone else already said.

 

[nater]

I just spoke with an intensivist about this last week. Fluids are desired in large amounts, 1 liter is probably not enough. Our protocols call for a goal of 30 ml/kg actual body weight with pressors added as needed to keep MAP >65. We carry Levo then add Epi for sepsis.