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Cardiogenic Shock: Which Vasopressor to use

In the patient who presents with cariogenic shock, the cath lab and a stent or a CABG is probably the treatment of choice, however we don’t always have those luxuries. What inotrope(s) do we use in cariogenic shock...

Consider starting with NorAdrenaline which had both alpha and beta effects and adding Dobutamine if needed. The diastolic blood pressure can help us in making this decision a pressor. Low diastolic blood pressure in the absence of bradycardia, indicated decreased arterial tone and the need for support.

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 Vasopressors in the ED

THE OTHER AGENTS: Almost never used in ED Dobutamine: - Mechanism: β agonism, no ⍺ - Indications: Bradycardia, cardiogenic shock - Dosage: Start at 2.5 mcg/kg/min (Max 20mcg/kg/min) - Notes: Poor-mans milrinone. (-) Bad dysrhythmias. (+/-) Not a true “pressor”; Can cause vasodilation via β2 without ⍺ activity.

Articles of Interest

Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock

In patients with cardiogenic shock, no significant difference between milrinone and dobutamine was found with respect to the primary composite outcome or important secondary outcomes.

Milrinone as compared with Dobutamine in the Treatment of Cardiogenic Shock

This trial found no significant difference in important outcomes between milrinone and dobutamine for patients with cardiogenic shock.

Pressors in cardiogenic shock

Dobutamine is typically recommended as the first line agent in cardiogenic shock , but this is not a strong recommendation because several studies have demonstrated benefits to norepinephrine in this setting.

Reassessment of Dobutamine, Dopamine, and Milrinone in the Management of Acute Heart Failure Syndromes

Randomized controlled trials failed to show benefits with current medications and suggested that acute, intermittent, or continuous use of inodilator infusions may increase morbidity and mortality in patients with AHFS. Their use should be restricted to patients who are hypotensive as a result of low cardiac output despite a high left ventricular filling pressure.

The value of contrast dobutamine stress echocardiography in detecting coronary artery disease in overweight and obese patients

Dobutamine stress echocardiography (DSE) is an established method of detecting myocardial ischemia. Its diagnostic accuracy solely depends on wall motion assessment.

Vasopressors for Septic Shock (from the Surviving Sepsis Guidelines)

A dobutamine infusion up to 20 mcg/kg/min can be added to any vasopressor(s) in use. Dobutamine is also an appropriate first-line agent in patients with severe sepsis and low cardiac output, with a preserved mean arterial pressure (i.e., who are not in septic shock) (Grade 1C).

Resources

Life in the Fastlane

No evidence that Dobutamine is to be used in any situation over other similar agents.

ScienceDirect

Dobutamine is an apparently β1-selective adrenoceptor agonist which clinically is used as a positive inotrope in the treatment of heart failure and as an emergency treatment for cardiogenic shock.

StatPearls

In 1975, pharmacologist Tuttle and chemist Mills, discover the compound dobutamine by modifying the structure of isoproterenol/isoprenaline. They published an article "Dobutamine: development of a new catecholamine to selectively increase cardiac contractility.