NE and Dobutamine or Epinephrine alone?
In a recent study published from France compared epinephrine and norepinephrine-dobutamine in dopamine-resistant cardiogenic shock. It was an open, randomized interventional human study.
Thirty patients with a cardiac index of less than 2.2 and a mean arterial pressure of less than 60 mm Hg who were resistant to combined dopamine-dobutamine treatment and signs of shock were included. Patients were randomized to receive an infusion of either norepinephrine-dobutamine or epinephrine titrated to obtain a mean arterial pressure of between 65 and 70 mm Hg with a stable or increased cardiac index.
It was found that
- both regimens increased cardiac index and oxygen-derived parameters in a similar manner.
- Patients in the norepinephrine-dobutamine group demonstrated heart rates lower than those in the epinephrine group.
- Epinephrine infusion was associated with new arrhythmias in three patients.
- When compared to baseline values, after 6 hrs, epinephrine infusion was associated with an increase in lactate level, whereas this level decreased in the norepinephrine-dobutamine group.
- Tonometered PCO2 gap, a surrogate for splanchnic perfusion adequacy, increased in the epinephrine-treated group while decreasing in the norepinephrine group.
- Diuresis increased in both groups but significantly more so in the norepinephrine-dobutamine group, whereas plasma creatinine decreased in both groups.
It was concluded that when considering global hemodynamic effects, epinephrine is as effective as norepinephrine-dobutamine. Nevertheless, epinephrine is associated with a transient lactic acidosis, higher heart rate and arrhythmia, and inadequate gastric mucosa perfusion. Thus, the combination norepinephrine-dobutamine appears to be a more reliable and safer strategy.
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