The current Surviving Sepsis Campaign guidelines recommend starting either dopamine up to 10mcg/kg/min or epinephrine 0.05 mcg/kg/min for pediatric patients suffering from fluid-refractory septic shock. There is a significant lack of evidence as to which of the two agents is most beneficial, however, until a recent study published in Critical Care Medicine attempted to address the issue.
The study published is a double-blind, prospective, randomized controlled utilizing 121 patients ages 1 month to 15 years old who were randomized to receive either dopamine or epinephrine as first line vasopressor for fluid-refractory septic shock. There were no differences in patient demographics, disease severity, or offending organisms grown on cultures.
What they found was that use of dopamine significantly increased mortality risk as well as risk of healthcare-associated infections in these patients. Out of 17 deaths in the cohort, 13 were in the dopamine group and 4 were in the epinephrine group. Patient who received dopamine as a first line agent were found to have a 6.51-fold increased chance of death in comparison with patient who received epinephrine and a 67.7-fold increased chance of developing healthcare-associated infection (all statistically significant). The study was ended early due to an increased risk in patients receiving dopamine.
It should be noted that in this study there were several limitations. For example, use of dopamine was significantly shorter than use of epinephrine (20.4 hrs vs 36.5 hrs), presumably because patients did not respond well to dopamine. Additionally, dosing of medications were not assessed. Also notable is that this was a single-center study and as such should be reproduced prior to making this standard of practice.
Nonetheless, the findings were powerful and will undoubtedly be cause for further exploration into the topic.
Sources:
Ventura AM et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med 2015. PMID 26323041
Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee Including the Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637.
