Epinephrine or Dopamine? Results may shock you

Andrea Cruz (Texas Children’s) and Michelle Macy (Michigan) presented the best PEM-related articles of 2016 at AAP this past October. If you weren’t in the room that day, we’re going to be counting them down over here over the next few weeks.

Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock

Ventura AM1, Shieh HH, Bousso A, et al. Critical Care Medicine. 2015.

Unmet Needs Addressed

Sepsis results in high rates of mortality. That is a problem. While some diagnostic and treatment guidelines for pediatric sepsis exist, some areas remain debatable. One of those debates is what is the best first-line vasoactive infusion for children with fluid-refractory shock?

Methods

  • Single center, prospective, randomized, double-blind trial in a pediatric ICU in São Paulo, Brazil
  • Children 1 month to 15 years old who met clinical criteria for fluid-refractory septic shock were screened for eligibility
  • Exclusion: Children receiving vasoactive drug(s) before hospital admission, known cardiac disease, prior study enrollment during same hospital stay, DNR
  • Data were collected between 2009-2013
The study defined fluid-refractory shock as:

Clinical signs of hypo-perfusion

  • Abnormal heart rate for age
  • Altered/decreased mental status
  • Altered capillary refill time (>2 seconds or flash)
  • Diminished or impalpable or bounding peripheral pulses
  • Mottled cool extremities
  • Urine output <1ml/kg/hr

DESPITE fluid bolus of at least 40 ml/kg

They compared various doses of epinephrine (0.1, 0.2, and 0.3 mcg/kg/min) and dopamine (5, 7.5, and 10 mcg/kg/min) via a PIV or intraosseous line.

Main Results

There were 120 children with fluid-refractory septic shock studied.

Check out the Kaplan-Meyer for epinephrine versus dopamine.

It’s not clear how the editors allowed this chart to use shades of grey for the lines instead of a dotted line. But it suggests that children in the dopamine group died earlier and children in the epinephrine group had an increased odds of survival (6.49). The rate of adverse events were similar.

The dopamine group had a higher percentage for hospital-associated infections compared to the epinephrine group (18/63 patients and 4/57 patients, respectively).

How Did This Make Our Top 10?

Using epinephrine as the first-line vasoactive infusion for children with fluid refractory shock was superior to dopamine. The results admittedly must be replicated.

In addition, peripheral and intraosseous lines were effectively used for early initiation of vasoactives.

Andrea Cruz MD MPH

Andrea Cruz MD MPH

Associate Professor of Pediatrics in Emergency Medicine and Infectious Diseases at Baylor College of Medicine
Andrea is the PECARN site PI for Texas Children’s Hospital and runs the Data Center for the Pediatric Emergency Medicine Collaborative Research Committee.
Andrea Cruz MD MPH
Andrea Cruz MD MPH

Andrea Cruz MD MPH

Andrea is the PECARN site PI for Texas Children’s Hospital and runs the Data Center for the Pediatric Emergency Medicine Collaborative Research Committee.

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