Dopamine in septic shock

[VFlutter]

Seems like some have already hit this on the head... Why is the pressure low=osmotic shift, rate / contraction increase ( chrono/ino) will capitate the pump ( can't force through or oncrease thtough rate volume that's not present) marked increased HR (chrono )in septic shock accelerates potassium dump and cardiac arrhythmia potentials... If there was no option... Bolus, Bolus, piggy Dope@ bare minimum and prepare to override pace since u won't be able to turn back... Better plan would be Neo!! or # 2 in my book high volume low dose Epi drip while watching those "T" waves w bicarbonate and cal chlor on hand...

What in the name of sweet baby Jesus are you talking about? I can't even...


On a side note, we frequently get septic train wrecks from outside hospitals on Dopamine. It seems that is all they are comfortable with.

We usually start with Levo and then add vaso if needed. Rarely an Epi drip if they are in extremis and usually on CRRT at that point. I only see Neo used on our post op carotids.

 

[TransportJockey]

We tend to combo dobutamine and levo for our train wreck septic patients...
And I'm glad I wasn't the only one who was having trouble with what that poster up there said

 

[VFlutter]

We tend to combo dobutamine and levo for our train wreck septic patients...

I wasn't around for the "Every Septic Patient gets a Swan" phase but it is an amazing learning experience shooting numbers with vasoactive drips and seeing how they effect the various hemodynamic values. Nowadays we don't ever use them.

 

[TransportJockey]

I wasn't around for the "Every Septic Patient gets a Swan" phase but it is an amazing learning experience shooting numbers with vasoactive drips and seeing how they effect the various hemodynamic values. Nowadays we don't ever use them.

We were doing that with our new NICOM last tour at work. It is pretty cool to see exactly what they change

 

[Summit]

Dopamine is falling out of favor due to some recent research showing increases mortality vs other pressors in certain patient population. On vacation now will post more later

 

[Nova1300]

There was a large meta-analysis on this very topic published in 2012. Overall, dopamine was associated with a somewhat significant increase in arrhythmias. However, in the randomized trials looking at dopamine in sepsis there was a small (albeit "statistically significant") increase in risk of death. This increase had a relative risk of 1.2 when compared with norepi. Not terribly impressive, in my own opinion.

However, it makes sense from a physiology standpoint. Sepsis is usually a high cardiac output, hyperdynamic state. And while higher doses of dopamine will cause alpha agonism, you have to climb through a lot of inotrope effect to get there. And the last thing a patient with high cardiac output needs is more inotropy. Hence the likely reason for the increased incidence of arrhythmias.

If you want a funny read, check out the ARISE trial published in NEJM this month. 1600 patients, 51 centers randomized to protocolized early goal-directed therapy in sepsis or physician discretion (hey doc, do what you want and lets see what happens).

Answer - no mortality difference. Patients in protocolized groups had a higher fluid burden and got more vasopressors.

The "evidence" waxes and wanes with the moon.

 

[Brandon O]

In fairness, "physician discretion" meant pretty aggressive management. No real big differences in the stuff everyone agrees matters.

Nobody's doing the lazy man's sepsis care anymore.