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• W2000882326 abstract "Take-Home MessageDopamine administration is associated with a higher incidence of arrhythmias and increased risk of death compared with norepinephrine in the treatment of septic shock.MethodsData SourcesThe search included MEDLINE, EMBASE, Scopus databases, and the Cochrane registry of clinical trials (through June 30, 2011). Google Scholar, clinical trials.org, controlled-trials.com, and abstracts of major congresses (2005 to 2010) were also searched.Study SelectionStudies providing outcome data on the use of dopamine compared with norepinephrine in the treatment of septic shock were included; observational and randomized controlled trials were evaluated separately. Animal trials, pediatric trials, and crossover design trials were excluded.Data Extraction and SynthesisTwo authors independently extracted data from all studies, and the Cochrane risk of bias tool was used. Twenty-eight-day mortality, or the closest available mortality estimate, was the primary endpoint measured. A Forest plot was constructed and the combined relative risk of death was calculated. Risk of bias assessment was reported for all studies.ResultsA total of 5 observational studies and 6 randomized controlled trials, totaling 2,769 patients, were evaluated. In the observational studies, no difference in mortality was identified but significant heterogeneity existed. In the trial by Povoa et al,1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar patients who received both dopamine and norepinephrine were counted twice, yielding more septic shock patients than were included in the entire study, introducing a high risk of bias. This trial was deemed responsible for the substantial heterogeneity,1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar and after its exclusion, dopamine was associated with an increase in mortality compared with norepinephrine (Table). Among the randomized controlled trials, dopamine was associated with an increased risk of death and arrhythmias.Tabled 1Risk of death for treatment with dopamine compared with norepinephrine for the treatment of septic shock.GroupNumber of Patients (N)Relative Risk of Death (95% Confidence Interval)Observational studies Total1,3601.09 (0.84–1.41) Excluding Povoa et al1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar7951.23 (1.05–1.43)Randomized trials1,4081.12 (1.01–1.20) Open table in a new tab CommentarySeptic shock is a common, life-threatening condition observed in the emergency department, with mortality rates approaching 50%. Vasopressor agents, most commonly dopamine or norepinephrine, are frequently required in addition to intravenous fluids to correct hypotension. Both agents have α-adrenergic properties yielding vasopressor effects, but dopamine has more β-adrenergic and dopaminergic properties, which may lead to tachycardia and arrhythmic events. Current guidelines recommend treatment with either dopamine or norepinephrine for septic shock, and this meta-analysis sought to determine whether one is superior to the other.When the 5 observational study results were pooled, there was initially no difference in mortality. However, after excluding the trial that was at high risk of bias and responsible for the substantial heterogeneity identified,1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar dopamine administration was associated with an increase in mortality (relative risk [RR] 1.23; 95% confidence interval [CI] 1.05 to 1.43). When the randomized controlled trials were combined, there was also an increased risk of death for patients treated with dopamine (RR 1.12; 95% CI 1.01 to 1.20). These results are similar to those of a recent systematic review by Vasu et al2Vasu T.S. Cavallazzi R. Hirani A. et al.Norepinephrine or dopamine for septic shock: a systematic review of randomized clinical trials.J Intensive Care Med. March 24, 2011; ([Epub ahead of print])PubMed Google Scholar (RR 1.10; 95% CI 1.01 to 1.20) but differ slightly from those obtained by Havel et al3Havel C. Arrich J. Losert H. et al.Vasopressors for hypotensive shock.Cochrane Database Syst Rev. 2011; (CD003709)PubMed Google Scholar (RR 1.05; 95% CI 0.97 to 1.15). Both of these reviews evaluated the effects of dopamine and norepinephrine but included patients with septic shock and other types of shock, which may explain the slightly different results.Several limitations to this meta-analysis exist. In the randomized controlled trials, there was significant variability in exposure times to the medications, the time at which outcomes were evaluated, and the endpoints that were assessed. The author of this meta-analysis is also the author of the largest of the included randomized controlled trials,4De Backer D. Bistonn P. Devriendt J. et al.Comparison of dopamine and norepinephrine in the treatment of shock.N Engl J Med. 2010; 362: 779-789Crossref PubMed Scopus (1148) Google Scholar and the impartial evaluation of one's own work might be difficult. Nonetheless, this meta-analysis suggests that dopamine is associated with a higher mortality and rate of arrhythmia compared with norepinephrine for the treatment of septic shock. Take-Home MessageDopamine administration is associated with a higher incidence of arrhythmias and increased risk of death compared with norepinephrine in the treatment of septic shock. Dopamine administration is associated with a higher incidence of arrhythmias and increased risk of death compared with norepinephrine in the treatment of septic shock. MethodsData SourcesThe search included MEDLINE, EMBASE, Scopus databases, and the Cochrane registry of clinical trials (through June 30, 2011). Google Scholar, clinical trials.org, controlled-trials.com, and abstracts of major congresses (2005 to 2010) were also searched.Study SelectionStudies providing outcome data on the use of dopamine compared with norepinephrine in the treatment of septic shock were included; observational and randomized controlled trials were evaluated separately. Animal trials, pediatric trials, and crossover design trials were excluded.Data Extraction and SynthesisTwo authors independently extracted data from all studies, and the Cochrane risk of bias tool was used. Twenty-eight-day mortality, or the closest available mortality estimate, was the primary endpoint measured. A Forest plot was constructed and the combined relative risk of death was calculated. Risk of bias assessment was reported for all studies. Data SourcesThe search included MEDLINE, EMBASE, Scopus databases, and the Cochrane registry of clinical trials (through June 30, 2011). Google Scholar, clinical trials.org, controlled-trials.com, and abstracts of major congresses (2005 to 2010) were also searched. The search included MEDLINE, EMBASE, Scopus databases, and the Cochrane registry of clinical trials (through June 30, 2011). Google Scholar, clinical trials.org, controlled-trials.com, and abstracts of major congresses (2005 to 2010) were also searched. Study SelectionStudies providing outcome data on the use of dopamine compared with norepinephrine in the treatment of septic shock were included; observational and randomized controlled trials were evaluated separately. Animal trials, pediatric trials, and crossover design trials were excluded. Studies providing outcome data on the use of dopamine compared with norepinephrine in the treatment of septic shock were included; observational and randomized controlled trials were evaluated separately. Animal trials, pediatric trials, and crossover design trials were excluded. Data Extraction and SynthesisTwo authors independently extracted data from all studies, and the Cochrane risk of bias tool was used. Twenty-eight-day mortality, or the closest available mortality estimate, was the primary endpoint measured. A Forest plot was constructed and the combined relative risk of death was calculated. Risk of bias assessment was reported for all studies. Two authors independently extracted data from all studies, and the Cochrane risk of bias tool was used. Twenty-eight-day mortality, or the closest available mortality estimate, was the primary endpoint measured. A Forest plot was constructed and the combined relative risk of death was calculated. Risk of bias assessment was reported for all studies. ResultsA total of 5 observational studies and 6 randomized controlled trials, totaling 2,769 patients, were evaluated. In the observational studies, no difference in mortality was identified but significant heterogeneity existed. In the trial by Povoa et al,1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar patients who received both dopamine and norepinephrine were counted twice, yielding more septic shock patients than were included in the entire study, introducing a high risk of bias. This trial was deemed responsible for the substantial heterogeneity,1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar and after its exclusion, dopamine was associated with an increase in mortality compared with norepinephrine (Table). Among the randomized controlled trials, dopamine was associated with an increased risk of death and arrhythmias.Tabled 1Risk of death for treatment with dopamine compared with norepinephrine for the treatment of septic shock.GroupNumber of Patients (N)Relative Risk of Death (95% Confidence Interval)Observational studies Total1,3601.09 (0.84–1.41) Excluding Povoa et al1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar7951.23 (1.05–1.43)Randomized trials1,4081.12 (1.01–1.20) Open table in a new tab A total of 5 observational studies and 6 randomized controlled trials, totaling 2,769 patients, were evaluated. In the observational studies, no difference in mortality was identified but significant heterogeneity existed. In the trial by Povoa et al,1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar patients who received both dopamine and norepinephrine were counted twice, yielding more septic shock patients than were included in the entire study, introducing a high risk of bias. This trial was deemed responsible for the substantial heterogeneity,1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar and after its exclusion, dopamine was associated with an increase in mortality compared with norepinephrine (Table). Among the randomized controlled trials, dopamine was associated with an increased risk of death and arrhythmias. CommentarySeptic shock is a common, life-threatening condition observed in the emergency department, with mortality rates approaching 50%. Vasopressor agents, most commonly dopamine or norepinephrine, are frequently required in addition to intravenous fluids to correct hypotension. Both agents have α-adrenergic properties yielding vasopressor effects, but dopamine has more β-adrenergic and dopaminergic properties, which may lead to tachycardia and arrhythmic events. Current guidelines recommend treatment with either dopamine or norepinephrine for septic shock, and this meta-analysis sought to determine whether one is superior to the other.When the 5 observational study results were pooled, there was initially no difference in mortality. However, after excluding the trial that was at high risk of bias and responsible for the substantial heterogeneity identified,1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar dopamine administration was associated with an increase in mortality (relative risk [RR] 1.23; 95% confidence interval [CI] 1.05 to 1.43). When the randomized controlled trials were combined, there was also an increased risk of death for patients treated with dopamine (RR 1.12; 95% CI 1.01 to 1.20). These results are similar to those of a recent systematic review by Vasu et al2Vasu T.S. Cavallazzi R. Hirani A. et al.Norepinephrine or dopamine for septic shock: a systematic review of randomized clinical trials.J Intensive Care Med. March 24, 2011; ([Epub ahead of print])PubMed Google Scholar (RR 1.10; 95% CI 1.01 to 1.20) but differ slightly from those obtained by Havel et al3Havel C. Arrich J. Losert H. et al.Vasopressors for hypotensive shock.Cochrane Database Syst Rev. 2011; (CD003709)PubMed Google Scholar (RR 1.05; 95% CI 0.97 to 1.15). Both of these reviews evaluated the effects of dopamine and norepinephrine but included patients with septic shock and other types of shock, which may explain the slightly different results.Several limitations to this meta-analysis exist. In the randomized controlled trials, there was significant variability in exposure times to the medications, the time at which outcomes were evaluated, and the endpoints that were assessed. The author of this meta-analysis is also the author of the largest of the included randomized controlled trials,4De Backer D. Bistonn P. Devriendt J. et al.Comparison of dopamine and norepinephrine in the treatment of shock.N Engl J Med. 2010; 362: 779-789Crossref PubMed Scopus (1148) Google Scholar and the impartial evaluation of one's own work might be difficult. Nonetheless, this meta-analysis suggests that dopamine is associated with a higher mortality and rate of arrhythmia compared with norepinephrine for the treatment of septic shock. Septic shock is a common, life-threatening condition observed in the emergency department, with mortality rates approaching 50%. Vasopressor agents, most commonly dopamine or norepinephrine, are frequently required in addition to intravenous fluids to correct hypotension. Both agents have α-adrenergic properties yielding vasopressor effects, but dopamine has more β-adrenergic and dopaminergic properties, which may lead to tachycardia and arrhythmic events. Current guidelines recommend treatment with either dopamine or norepinephrine for septic shock, and this meta-analysis sought to determine whether one is superior to the other. When the 5 observational study results were pooled, there was initially no difference in mortality. However, after excluding the trial that was at high risk of bias and responsible for the substantial heterogeneity identified,1Povoa P.R. Carneiro A.H. Ribeiro O.S. et al.Influence of vasopressor agent in septic shock mortality Results from the Portuguese Community-Acquired Sepsis Study (SACiUCI Study).Crit Care Med. 2009; 37: 410-416Crossref PubMed Scopus (63) Google Scholar dopamine administration was associated with an increase in mortality (relative risk [RR] 1.23; 95% confidence interval [CI] 1.05 to 1.43). When the randomized controlled trials were combined, there was also an increased risk of death for patients treated with dopamine (RR 1.12; 95% CI 1.01 to 1.20). These results are similar to those of a recent systematic review by Vasu et al2Vasu T.S. Cavallazzi R. Hirani A. et al.Norepinephrine or dopamine for septic shock: a systematic review of randomized clinical trials.J Intensive Care Med. March 24, 2011; ([Epub ahead of print])PubMed Google Scholar (RR 1.10; 95% CI 1.01 to 1.20) but differ slightly from those obtained by Havel et al3Havel C. Arrich J. Losert H. et al.Vasopressors for hypotensive shock.Cochrane Database Syst Rev. 2011; (CD003709)PubMed Google Scholar (RR 1.05; 95% CI 0.97 to 1.15). Both of these reviews evaluated the effects of dopamine and norepinephrine but included patients with septic shock and other types of shock, which may explain the slightly different results. Several limitations to this meta-analysis exist. In the randomized controlled trials, there was significant variability in exposure times to the medications, the time at which outcomes were evaluated, and the endpoints that were assessed. The author of this meta-analysis is also the author of the largest of the included randomized controlled trials,4De Backer D. Bistonn P. Devriendt J. et al.Comparison of dopamine and norepinephrine in the treatment of shock.N Engl J Med. 2010; 362: 779-789Crossref PubMed Scopus (1148) Google Scholar and the impartial evaluation of one's own work might be difficult. Nonetheless, this meta-analysis suggests that dopamine is associated with a higher mortality and rate of arrhythmia compared with norepinephrine for the treatment of septic shock." @default.
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• W2000882326 title "Dopamine Versus Norepinephrine for the Treatment of Septic Shock EBEM Commentators" @default.
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