Dopamine in Sepsis?

[CWATT]

According to the video below, the Surviving Sepsis Campaign protocols cite hypotensive management priority as Norepinepherine, Vasopressin, then Epinepherine, and Dopamine ONLY indicated in patients at low risk of tachydysrhymias. They also cite doBUTamine as possibly exacerbating hypotension.

However, I have protocols in two jurisdictions that cite Dopamine as the vasopressor for hypotension associated with sepsis.

I'm just wondering if anyone has any insight on what might be contributing to this discrepancy. Are the protocols in my jurisdictions antiquated? Also, why would a b1 agonist exacerbate hypotension? Especially when combined with a vasopressor.

Vasopressors @ 4:00mins

- C

 

[Handsome Robb]

We use levophed and epi, don't even carry dopamine anymore.

Dobutamine would be a very poor choice for a septic person as it is an inotrope but also causes mild vasodilation which is the exact problem in septic shock.


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[Carlos Danger]

According to the video below, the Surviving Sepsis Campaign protocols cite hypotensive management priority as Norepinepherine, Vasopressin, then Epinepherine, and Dopamine ONLY indicated in patients at low risk of tachydysrhymias. They also cite doBUTamine as possibly exacerbating hypotension.

However, I have protocols in two jurisdictions that cite Dopamine as the vasopressor for hypotension associated with sepsis.

I'm just wondering if anyone has any insight on what might be contributing to this discrepancy. Are the protocols in my jurisdictions antiquated? Also, why would a b1 agonist exacerbate hypotension? Especially when combined with a vasopressor.

I don't think there is a lot of strong evidence for one vasopressor over another. That said, norepi has enjoyed a resurgence recently while dopamine has fallen out of favor for most applications. surviving sepsis guidelines are largely consensus-based and every recommendation is not necessarily the result of clear evidence. Personally I think norepi is easier to use. Dopamine is a "dirty" drug and cause cause significant tachycardia and dysrhythmias, along with other side effects.

Dobutamine would be fine in combination with a vasopressor. That was not an uncommon regimen before norepi became popular again.

 

[StCEMT]

Is the inotropic effect of dobutamine beneficial in sepsis assuming you have an appropriately dosed vasopressor to help maintain bp? Or is that more of just a nice extra if you do have it?

 

[Carlos Danger]

Is the inotropic effect of dobutamine beneficial in sepsis assuming you have an appropriately dosed vasopressor to help maintain bp? Or is that more of just a nice extra if you do have it?

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.

 

[StCEMT]

What's the general in hospital opinion on having someone come in with an epi drip? I never had a moment come up to start a drip once I switched over to the tech spot and fortunately I now have norepi among my meds, but it was something I kept preset mixing calculations on since I went to nursing homes A LOT.

At least what bit I remember on the pressor A vs pressor B argument, epi isn't too bad of a choice and it's not like we have trouble scrounging some up for a simple drip. Maybe in @CWATT's case, this is an alternative worth asking about if the need ever arises.

 

[Carlos Danger]

The problem with epi is it is pretty tough on the heart. At lower doses the beta effects predominate, and you can get some mild peripheral vasodilation. You have to give higher doses in order for alpha effects to predominate and get the desired pressor effect. All this adds up to a lot of increased cardiac work. Coronary vasodilation may not increase supply enough to meet the demand, especially at high heart rates.

Norepi is the opposite: alpha effects predominate and beta effects are more proportionate to the increased afterload. You generally get less tachycardia. Less likely to cause an imbalance between myocardial oxygen supply and demand.

Either one can cause end-organ ischemia at high doses.

 

[E tank]

NE is better in sepsis than dopamine. 30 day in hospital mortality is less....or something. Can't remember. It can be googled for the interested.

(caveat emptor....better when used with appropriate volume resuscitation.)

 

[StCEMT]

Hmm, ok makes sense, thanks for breaking that down a bit more. I've read some of the articles on the options, but they don't really give the why that you did as much as simply comparing the end results.

 

[Carlos Danger]

NE is better in sepsis than dopamine. 30 day in hospital mortality is less....or something. Can't remember. It can be googled for the interested.

I think that is correct. They've been saying that for a while. But IIRC the evidence supporting this statement isn't all that robust. I've been wrong before though.

 

[VFlutter]

Is the inotropic effect of dobutamine beneficial in sepsis assuming you have an appropriately dosed vasopressor to help maintain bp? Or is that more of just a nice extra if you do have it?

Most patients with sepsis are hyper dynamic due to nonexistent afterload and high sympathetic tone. Later stages in sepsis when patients become profoundly acidotic with cardiac dysfunction it may have a place however at that point it may not be very effective.

 

[NPO]

I talked to a former paramedic of ours who now works at our county LEMSA. I specifically talked to him about dopamine in sepsis because they are developing a sepsis protocol. Currently the only way our protocol includes dopamine for sepsis is reading between the lines in our Shock/Hypotension protocol, which is actually in our trauma protocol section, but doesn't specify anything about trauma in the protocol itself.

I asked him the same question OP brought up. He has been in EMS longer than I've been alive, and what he told me is that Levophed used to be in the scope of practice, but that it gained negative conotation because many patients with the drug had poor outcomes, but in retrospect that's likely due to the patients getting the med were very sick. The term "Levophed or leave em dead" didn't help.

He agreed that moving back to levo in favor of dopamine would be good, and have an added benefit of continuity of care since it's what the hospitals are using. But he admitted it's unlikely anytime soon.

Shame. They say trauma and heart disease are leading causes of death in the prehospital setting.

I wonder how many patients are killed by dogma.

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[Carlos Danger]

I talked to a former paramedic of ours who now works at our county LEMSA. I specifically talked to him about dopamine in sepsis because they are developing a sepsis protocol. Currently the only way our protocol includes dopamine for sepsis is reading between the lines in our Shock/Hypotension protocol, which is actually in our trauma protocol section, but doesn't specify anything about trauma in the protocol itself.

I asked him the same question OP brought up. He has been in EMS longer than I've been alive, and what he told me is that Levophed used to be in the scope of practice, but that it gained negative conotation because many patients with the drug had poor outcomes, but in retrospect that's likely due to the patients getting the med were very sick. The term "Levophed or leave em dead" didn't help.

He agreed that moving back to levo in favor of dopamine would be good, and have an added benefit of continuity of care since it's what the hospitals are using. But he admitted it's unlikely anytime soon.

Shame. They say trauma and heart disease are leading causes of death in the prehospital setting.

I wonder how many patients are killed by dogma.

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I don't like dogma either, but really I doubt any patients are going to be killed by EMS using dopamine in the field for sepsis instead of levo. Like I said before, I don't think the evidence supporting levo over dopamine is great, but even if it is, using dopamine for transport and then the intensivists in the ICU switching to whatever they think is most appropriate is probably not going to cause harm.

 

[NPO]

I don't like dogma either, but really I doubt any patients are going to be killed by EMS using dopamine in the field for sepsis instead of levo. Like I said before, I don't think the evidence supporting levo over dopamine is great, but even if it is, using dopamine for transport and then the intensivists in the ICU switching to whatever they think is most appropriate is probably not going to cause harm.

I'm not specifically referring to dopamine vs levo, but EMS's (at least in my state) unwillingness to adapt to changes and improvements in care.

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[FLMedic311]

I don't like dogma either, but really I doubt any patients are going to be killed by EMS using dopamine in the field for sepsis instead of levo. Like I said before, I don't think the evidence supporting levo over dopamine is great, but even if it is, using dopamine for transport and then the intensivists in the ICU switching to whatever they think is most appropriate is probably not going to cause harm.

I am sorry to say but this is not an accurate statement. Dopamine through plenty of studies has been shown to be associated with an increased mortality. The Surviving Sepsis Campaign being a valid one in and of itself. I do not believe that any single person on this forum is educated or experienced enough to speak against the recommendations of a committee of MD's whose sole commitment has been to research, test, and study the treatment of sepsis. Your statements are dogmatic..

 

[VFlutter]

I am sorry to say but this is not an accurate statement. Dopamine through plenty of studies has been shown to be associated with an increased mortality. The Surviving Sepsis Campaign being a valid one in and of itself. I do not believe that any single person on this forum is educated or experienced enough to speak against the recommendations of a committee of MD's whose sole commitment has been to research, test, and study the treatment of sepsis. Your statements are dogmatic..

I think Remi was talking about short term prehospital use as opposed to prolonged use in the ICU which is what surviving sepsis is really talking about. I agree that using Dopamine vs Levophed to initially stabilize a patient for an hour until they get to the ER/ICU is not an issue.

 

[FLMedic311]

I can appreciate what you're saying about the difference in short vs long term use. Reading through all the post it does not seem that way and my concern is that it comes off as saying using Dopamine is not a big deal, when in fact it is.. If you have a pt dying of sepsis about to arrest and you have no other pressor available and you grab dopamine, ok.. But the matter of the fact is you had a better option, Epi, and everyone has it. Even short term use in high enough doses will increase urine output potentially causing worsening hypovolemia.

 

[FLMedic311]

I will say @Remi I apologize, when reading my initial post my words come off harsh off my tongue and I am not trying to incite conflict as much as conversation and consideration. Having read a number of your posts I know you are not only intelligent but well intended in your comments

 

[Carlos Danger]

I am sorry to say but this is not an accurate statement. Dopamine through plenty of studies has been shown to be associated with an increased mortality. The Surviving Sepsis Campaign being a valid one in and of itself. I do not believe that any single person on this forum is educated or experienced enough to speak against the recommendations of a committee of MD's whose sole commitment has been to research, test, and study the treatment of sepsis. Your statements are dogmatic..

Well first, I did not "speak against" any recommendations. Never did I say that the surviving sepsis guidelines were wrong or that they shouldn't be followed. I simply said that to my understanding, the strength of the data supporting norepi over dopamine was not overwhelming. I even wrote "but I've been wrong before" to indicate that I wasn't 100% sure about that. I read the 2016 guidelines when they came out and I'm pretty familiar with them, but as someone who doesn't manage patients in the unit, I don't make it a big priority to stay up-to-the minute on all the nitty gritty details.

Then after you called me out here, I went back and reviewed the section of the guidelines that discusses vasopressors. Turned out I was right after all. On page 19 of the guidelines, under Section G, "Vasoactive Medications", the very first line says "We recommend norepinephrine as the first choice vasopressor (strong recommendation, moderate quality of evidence). I briefly looked at the meta analysis that this recommendation is based on, and without getting to far into the weeds discussing the studies in the meta-analysis, suffice it to say that it's pretty clear why the authors of the study describe the quality of evidence as "moderate" rather than "high". Don't confuse quantity of evidence with quality of evidence.

Second, the guidelines themselves are not evidence. They are a consensus document formed from the opinions of a group of clinicians from various backgrounds (most of whom are NOT researchers themselves, as you claim), many of which may not even agree all that strongly with certain parts of the final recommendations. I happen to think the Surviving Sepsis guidelines are pretty solid (I think all of the SCCM's recommendations are about as good as they come), but don't forget that it was "the experts" who used to tell us that high-dose epi was good for cardiac arrests, that backboards should be used on all trauma patients, that bleeding patients should receive enough IVF to raise their BP to a near normal level, that everyone should get high-flow oxygen, and that 10-15 ml/kg was a good tidal volume. We could go on and on with stuff that "experts" have been wrong about.

Lastly, I doubt that there is any evidence at all that the choice of vasopressor in the prehospital phase affects eventual outcomes, certainly not large, high-quality studies. Unless that data does in fact exist, you can't make the claim that using dopamine prehospital for sepsis has any impact.

Your statements are dogmatic..

Skepticism is actually the opposite of dogma. Don't blindly accept everything that you read or are told. Look it up and evaluate the the validity and importance for yourself. Be a clinician, not a drone.

 

[FLMedic311]

Skepticism is actually the opposite of dogma. Don't blindly accept everything that you read or are told. Look it up and evaluate the the validity and importance for yourself. Be a clinician, not a drone.

I have no problem with Constructive Skepticism, I do believe that the phenomena of sepsis like all forms of resuscitation has a long ways to go and we may never know the true answer to what is actually best practice. However, when you doubt something only for the sake of suspicion, that is destructive. The only way we progress forward from guidelines with moderate quality of evidence is better research. In the meantime, the best we have is simply that and there is plenty of evidence to suggest that Dopamine has increased mortality compared to both Epi and NE.

I doubt any patients are going to be killed by EMS using dopamine in the field for sepsis instead of levo.

Just to clarify, this is the only thing I was referring to. All of your prior statements to this one I agree with 100%. Based on your response it appears as though you felt like I was referencing everything you have said, and that is not what I intended. I simply meant this one statement