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Clinical question: Do clinical outcomes differ with the use of dopamine and norepinephrine in the treatment of shock?

Background: Observational trials have suggested higher mortality among patients with shock who are treated with dopamine versus norepinephrine; however, there are limited data from randomized trials.

Study design: Randomized, double-blinded trial.

Setting: Eight ICUs in Europe.

Synopsis: The study enrolled 1,679 consecutive adult patients with shock despite intravenous fluids. Of these, 62.2% were classified as septic shock, 16.7% cardiogenic, and 15.7% hypovolemic. Clinicians titrated the blinded study drug (dopamine or norepinephrine) according to a pre-specified algorithm. If shock persisted despite titration of their study drug to a goal rate, then open-label norepinephrine was added, followed by epinephrine or vasopressin if necessary.

No difference in 28-day mortality between dopamine and norepinephrine (52% versus 48% of patients; odds ratio 1.17 (0.97-1.42); P=0.10) was detected. Patients receiving dopamine experienced more frequent (24% vs. 12%, P<0.001) and more severe arrhythmias (6.1% vs. 1.6%, P< 0.001).

In subgroup analysis, patients in cardiogenic shock had significantly increased 28-day mortality with dopamine (P=0.03).

Study limitations include the use of norepinephrine as an open-label treatment and the inclusion of patients in hypovolemic shock, who are not typically treated with vasopressors.

Bottom line: No mortality difference is detected between dopamine and norepinephrine in patients with shock. Dopamine results in increased rates of mortality in cardiogenic shock and serious arrhythmias in all patients.

Citation: De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779-789.

Reviewed for TH eWire by Robert Chang, MD, Anita Hart, MD, Hae-won Kim, MD, Robert Paretti, MD, Helena Pasieka, MD, and Matt Smitherman, MD, University of Michigan, Ann Arbor

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