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DES PLAINES, Ill. Patients in septic shock who respond to dopamine, a commonly used sepsis therapy to stabilize blood pressure, have a better chance of survival than those who did not respond to dopamine, according to an article in the October issue of Critical Care Medicine.
Patient prognosis is dramatically better when dopamine alone can increase blood pressure, and patients do not require treatment with other vasopressor such as norepinephrine or epinephrine, said lead author Bruno Levy, MD, PhD, professor of Intensive Care Medicine at RÃ©animation MÃ©dicale at HÃ´pital Central in Nancy, France.
Sepsis is the leading cause of death in critically ill patients, and it is fatal for 30 percent to 50 percent of them. The Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis And Septic Shock suggests dopamine or norepinephrine as first line agents in septic shock treatment.
The researchers studied 110 septic shock patients who were treated with a dopamine infusion from 10 to 20 Âµg/kg/min to evaluate the predictive value of dopamine resistance on mortality. If arterial blood pressure remained low, below 70 mm Hg, dopamine treatment was promptly switched to norepinephrine or epinephrine. The prospective, multicenter clinical trial was conducted in 10 intensive care units (ICUs) in 10 French hospitals.
The investigators found that 66 (60 percent) of the 110 patients were resistant to dopamine and 44 (40 percent) responded. Approximately 78 percent of the resistant patients died within 28 days, while only 16 percent of the dopamine sensitive group died. The overall 28-day mortality rate was 54 percent for the entire population in the study.
This study is the first demonstration of the temporal relationship between patient prognosis and vasopressor dosages, together with a precise protocol for administering vasopressors, says Levy. This enables physicians to implement a therapeutic test that is progressive over time. This test will enable clinicians to evaluate patient prognosis at every moment of their evolution and it may then prompt expensive additional treatments such as activated protein C at the appropriate time.
Levy comments that dopamine use in septic shock patients is safe and allows early identification of those with poor prognosis. His ICU is already using dopamine sensitivity as a prognosis indicator.
In an accompanying editorial, Jan Bakker, MD, PhD, says that Levys findings have implications for clinical practice and research. First, the identification of patients with a poor prognosis early in the process of resuscitation could help the clinician to guide additional hemodynamic diagnostics. Secondly, therapy could be optimized by implementation of new strategies (steroids, activated protein C, etc.). Thirdly, this rapid identification could help to stratify patients in the design of clinical trials. Finally, it could help to characterize a group of patients in whom benefit from treatment may be limited and disproportional to the resources used.
Bakker, chair of intensive care at Erasmus MC University Medical Center Rotterdam in the Netherlands, concludes, Nonresponders to vasopressor therapy in septic shock have universally been associated with very high mortality rates. Therefore standardized dosing of vasopressor therapy might rapidly identify a group of patients that especially needs our attention both as a researcher but even more as an intensivist. After 30 minutes of vasopressor therapy sepsis patients who did not adequately respond to dopamine could be identified as being at high risk for death.
Considering the high percentage of lives lost in the ICU to sepsis, Dr. Levys findings merit broader investigation and consideration, said Joseph E. Parrillo, MD, editor-in-chief of Critical Care Medicine. Intensivists eventually will individualize the specific steps of sepsis treatment regimens based on findings such as this.
Source: Society of Critical Care Medicine