article198

SOAP II

"Dopamine and Norepinephrine in Shock". The New England Journal of Medicine. 2010. 362(9):779-789.

Clinical Question

Among patients with shock, is there a difference in outcomes between using dopamine or norepinephrine as the first-line vasopressor therapy?

Bottom Line

Among patients with shock, there was no significant difference in 28-day mortality between treatment with dopamine compared to norepinephrine; however, dopamine use was associated with an increased number of arrhythmic events and a higher mortality in patients specifically with cardiogenic shock.

Major Points

The optimal first-line vasopressor agent for the treatment of shock remains debated. While both dopamine and norepinephrine are commonly used, their differing receptor profile effects may result in different clinical outcomes. This multicenter randomized trial compared the two agents as first-line vasopressor therapy in patients with shock.

The primary outcome was the rate of death at 28 days post-randomization, with secondary endpoints including adverse events, the number of days without the need for organ support, and mortality at various time points up to 12 months. The trial concluded without significant differences in 28-day or longer-term mortality rates between the two groups. However, dopamine was associated with a significant increase in arrhythmic events and higher mortality in the subgroup with cardiogenic shock.

Guidelines

This study prompts reconsideration of guidelines recommending dopamine as first-choice vasopressor in acute myocardial infarction-induced hypotension, given the increased rate of adverse events including arrhythmias and increased mortality in patients with cardiogenic shock treated with dopamine.

Design

- Multicenter, randomized, controlled, double-blind trial
- N=1,679 patients with shock
- Dopamine (n=858) versus Norepinephrine (n=821)
- Enrollment: December 19, 2003, to October 6, 2007
- Mean follow-up: 28 days
- Primary outcome: Death rate at 28 days post-randomization
- Secondary outcomes: Number of days without organ support, occurrence of adverse events

Population

- Adult patients with shock requiring vasopressor therapy
- Exclusions: Age <18, treatment with vasopressor for >4 hours in current shock episode, serious arrhythmia, brain death

Interventions

- Randomized to receive either dopamine or norepinephrine as first-line therapy to maintain blood pressure
- Open-label norepinephrine, epinephrine, or vasopressin added if necessary

Outcomes

- No significant between-group difference in the rate of death at 28 days
- Higher rate of arrhythmic events among those treated with dopamine versus norepinephrine (24.1% vs. 12.4%, P<0.001)
- Subgroup analysis indicated an increased mortality rate at 28 days with dopamine in patients with cardiogenic shock (P=0.03), but not in septic shock or hypovolemic shock

Criticisms

- Notable limitations include dopamine's lower potency as a vasopressor compared to norepinephrine and the sequential trial design potentially allowing for early study termination, though the trial included more patients than initially estimated

Funding

Supported in part by the European Society of Intensive Care through funding from the European Critical Care Research Network