March 4, 2010
Comparison of Dopamine and Norepinephrine in the Treatment of Shock.
What was the research question?
In patients with shock, does the use of dopamine improve 28-day mortality compared to norepinephrine?
How did they do it?
A multicenter, randomized trial in eight centers in Belgium, Austria, and Spain.
1679 patients with shock were randomized to receive either dopamine (858 patients) or norepinephrine (821 patients) as first-line vasopressor therapy to maintain a mean arterial pressure of 65 mm Hg. Open label vasopressors (norepinephrine, epinephrine, or vasopressin) could be added if the target was not achieved or maintained with 20 μg/kg/min of dopamine or 0.19 μg/kg/min of norepinephrine.
The primary outcome was 28-day mortality, and the secondary outcomes included the number of days without need for organ support and the occurrence of adverse events.
What did they find?
28-day mortality was not significantly different between the dopamine group and the norepinephrine group (52.5% vs. 48.5%, P=0.10).
There were more arrhythmic events (mostly atrial fibrillation) among the patients treated with dopamine compared to those treated with norepinephrine (24.1% vs. 12.4%, P<0.001).
Vasopressors free days were significantly worse for dopamine group compared to norepinephrine group (10 days vs. 12.5 days, P=0.01). No difference in ventilator-free days or renal failure-free days.
A subgroup analysis in predefined subgroups showed that patients with cardiogenic shock had significantly a higher 28-day mortality with dopamine compared to norepinephrine (p=0.03), but not with patients who had septic (P=0.19) or hypovolemic shock (P-0.84).
ICU, hospital, 6-month and 12-month mortality rates were not different between the groups.
Patients in the dopamine group required more open-label norepinephrine (26% vs. 20%, P<0.001), indicating that norepinephrine was more effective in achieving the goals.
What does it mean?
The rate of death was not different in patients treated with dopamine compared to norepinephrine. However, dopamine caused more arrhythmias in all groups and was associated with a higher rate of death in cardiogenic shock patients.
Use norepinephrine as a first-line agent in all types of shocks.