Dopamine in Sepsis?

[Alan L Serve]

Epi will bring up the pressure but it decreases cerebral blood flow. Pick your poison- low BP or low brain.

 

[VFlutter]

Epi will bring up the pressure but it decreases cerebral blood flow. Pick your poison- low BP or low brain.

Epi causing reduced cerebral blood flow during CPR in pigs should not deter you from using it as a vasopressor in shock. Significant hypotension can cause watershed infarcts just as easily in critically ill patients.

 

[MackTheKnife]

I can't think of any reason to use dobutamine + a vasopressor over norepi or dopamine.

When you used to see it done I think it was probably because the dopamine had caused too much tachycardia, or they wanted to avoid tachycardia in the first place. And for a couple decades almost no one used norepi because it just had a really bad rap.

Levophed- Leave 'Em Dead.

Sent from my XT1585 using Tapatalk

 

[Summit]

This is the norepi vs dopamnine metanalysis published in CCM in 2012
https://www.ncbi.nlm.nih.gov/pubmed/22036860

METHODS AND MAIN RESULTS:
We retrieved five observational (1,360 patients) and six randomized (1,408 patients) trials, totaling 2,768 patients (1,474 who received norepinephrine and 1,294 who received dopamine). In observational studies, among which there was significant heterogeneity (p < .001), there was no difference in mortality (relative risk, 1.09; confidence interval, 0.84-1.41; p = .72). A sensitivity analysis identified one trial as being responsible for the heterogeneity; after exclusion of that trial, no heterogeneity was observed and dopamine administration was associated with an increased risk of death (relative risk, 1.23; confidence interval, 1.05-1.43; p < .01). In randomized trials, for which no heterogeneity or publication bias was detected (p = .77), dopamine was associated with an increased risk of death (relative risk, 1.12; confidence interval, 1.01-1.20; p = .035). In the two trials that reported arrhythmias, these were more frequent with dopamine than with norepinephrine (relative risk, 2.34; confidence interval, 1.46-3.77; p = .001).

For peds, epi vs dopamine this prospect db rct showed a marked increased in mortality for use of dopamine. Treating with dopamine vs epi, number needed to harm was 8.
https://www.ncbi.nlm.nih.gov/pubmed/26323041

You can msg me if your institution doesn't have access.

 

[Summit]

I guess my thought is that depending on what we think underlies the difference in mortality. Studies had mean exposure time to vasopressors of 2 days.

Authors from the metastudy note:
"Fifth, the time of exposure in a randomized fashion to dopamine or norepinephrine was limited to a few hours in some of the randomized trials (25, 29, 30), and there was no mention of which vasopressor agent was used thereafter in these patients (patients may have received the alternate drug later on in their course). Any exposure to dopamine or norepinephrine may influence outcome and incorporating trials with short exposures in the analysis may limit the chance to disclose differences between the agents. Nevertheless, limiting the analysis to the three trials that ensured maximal exposure to trial drugs provided similar results"

So if I consider RR of 1.12 for the dopa or norepi or OR 6.7 for dopa and epi, I start thinking that the 1-2 hours of EMS vasopressor treatment would make an outsized difference relative to the still significant portion of the treatment time, particularly managing the sicker patient that is getting an EMS vasopressor treatment where it seems necessary in the field. Now that is speculation on my part... but it is speculation based on the evidence.

Both norepi and dopamine are both reasonable short term peripheral pressors... so... (and if they are sick enough to need a vasopressor, IO them)

 

[medicsb]

I think dopamine and epi are adequate as far as pressers for EMS. Dopamine may not be necessary since push dose epi would be fine in an urban or dense suburban setting. Dopamine is far far more likely to expire than be used on a patient Having work for an ALS service that cover 2 counties with a combined population of 900,000, we used dopamine maybe 3 times a year and those were usually post-arrest patients. When it comes to sepsis, most clinicians (myself included) prefer to get a couple liters in to the patient before initiating pressers. I can't think of a time where I initiated a pressor on a patient within the first 30 minutes of care other than in the post cardiac arrest patient (in those cases, I typically use epi). Actually, I don't think I've done it within an hour.

 

[truetiger]

Why would dopamine and epi be adequate for EMS? Why not levo? Why not use the proper drug? Why would you give a presumably tachycardic patient dopamine? I always hear the argument, well we only use drug x so many times a year. But what about those times we needed that drug? I think we owe it to our communities to stock the drugs needed to do the job and be competent on their use. Any service with extended transport times should be prepared to encounter any and all disease processes.

 

[TXmed]

Why would dopamine and epi be adequate for EMS? Why not levo? Why not use the proper drug? Why would you give a presumably tachycardic patient dopamine? I always hear the argument, well we only use drug x so many times a year. But what about those times we needed that drug? I think we owe it to our communities to stock the drugs needed to do the job and be competent on their use. Any service with extended transport times should be prepared to encounter any and all disease processes.

I understand what youre saying, and i dont necessarily disagree.

But, epi is in my opinion a very versatile drug when used properly. And all of these medications are dangerous when used improperly. So i would much rather have a group of medics very familiar and knowledgable with epi (or dopamine or levo). Than kinda familiar with 3 pressors+ 2 inotropes+ etc. And whether paramedics care to admit it or not, you will NOT be profeciant with these meds if you only use them once every 3-4years.

 

[truetiger]

I don't think it would be asking too much to be proficient in 3 vasopressors. I can't see administering EPI to a tachycardic patient turning out well.

 

[Summit]

I don't think it would be asking too much to be proficient in 3 vasopressors. I can't see administering EPI to a tachycardic patient turning out well.

Uh... huh?

 

[TXmed]

They do it for sepsis patients

 

[truetiger]

Do what for septic patients?

 

[TXmed]

Epinephrine for sepsis patient. And generally they are tachy.

 

[truetiger]

Levo should be first line in sepsis....

 

[TXmed]

That doesnt mean its not some peoples first line. And that doesnt mean its not given to a patient whos still tachy. Some people respond better to epi than the levo. Some people like vaso as 2nd line.

Point being you can use alot of these meds to accomplish the same task. Its just knowing how to use them to get the outcome you desire.

 

[truetiger]

But the thing is...it shouldn't be your first line.

 

[TXmed]

Well its first line in my hospital for cold sepsis.

 

[FLMedic311]

Well its first line in my hospital for cold sepsis.

I don't mean this to be a sarcastic question, but why? Has anybody stated a reason for this protocol I am curious! Thanks!

 

[TXmed]

Im still relatively new to this hospital/flight program. But from what ive been told and have seen. Most sever septic patients are catacholamine depleted and replacing those is the initial step. Not everyone is norepi depleted, not everyone is epi depleted, sometimes its neither and alot of times its both. Long story ahort they think in cold sepsis you need epi first and they respond better.

Its not a big deal anyways as theyre real big on stackong pressors so they rarely use jist epi or just levo. They would rather use both at 4mcg than one of them at 14mcg

 

[FLMedic311]

Interesting, and once again not accusing but on that theory are you guys carrying/using vasopressin?