Norepinephrine Probably Better Than Dopamine for Shock Comparison of Dopamine and Norepinephrine in the Treatment of Shock

Background: Consensus guidelines and expert recommendations suggest that either dopamine or norepinephrine can be used in the treatment of shock, but few randomized trials exist. Objective: To compare dopamine to norepinephrine as first-line vasopressor therapy in the treatment of shock. Design: Multicenter randomized head-to-head trial. Participants/Methods: In multiple European centers patients with shock who needed vasopressor therapy were enrolled between 2003 and 2007. Shock was defined as a mean arterial pressure <70 mm Hg or a systolic blood pressure <100 mm Hg despite getting intravenous fluids (1000 mL of crystalloid) and evidence of hypoperfusion (confusion, low urine output, elevated lactate). Enrolled patients were randomized to dopamine or norepinephrine infusions at standard dosing adjusted as needed. If patients remained hypotensive after maximal dosing, open-label norepinephrine was added. Results: 1679 patients were enrolled; 62% had septic shock, 17% cardiogenic shock, and 16% hypovolemic shock. There was no difference in 28-day mortality between the dopamine (52.5%) and norepinephrine groups (48.5%; P =0.10). There was also no difference in time to shock resolution, rates of ICU death, in-hospital death, or death at 6 and 12 months between the 2 groups. There was no difference in the amount of fluids given or the doses of open-label norepinephrine needed. Arrhythmias were much more common in the dopamine group (24.1% vs 12.4%; P <0.001), especially atrial fibrillation. In subgroup analysis, in patients with cardiogenic shock, the 28-day mortality was significantly higher in the dopamine group compared to the norepinephrine group (P =0.03 by Kaplan-Meier). Conclusions: There was no difference in overall mortality between dopamine and norepinephrine in patients with shock but dopamine was associated with an increased risk of arrhythmia and increased mortality in patients with cardiogenic shock. Reviewer's Comments: There is a long-standing belief that norepinephrine is associated with increased death (thus "Levophed" becoming "Leave-'em-dead"). This well-done study not only debunks that but proves that norepinephrine likely should be our first-line vasopressor in patients with shock that is not fluid responsive. Most guidelines (especially those for septic shock) state we can use either, but this study reveals overall outcomes are no different and rates of arrhythmia are much higher in the dopamine group. In addition, if you are managing patients with cardiogenic shock, dopamine should generally be avoided. (Reviewer-Bradley A. Sharpe, MD).