Effects of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in septic shock: which is best?
OBJECTIVE
To assess the effects of different doses of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in patients with septic shock.


METHODS
Prospective, randomized, open-label study.


METHODS
A 31-bed, medicosurgical intensive care unit of a university hospital.


METHODS
Convenience sample of 20 patients with septic shock, separated into two groups according to whether (moderate shock group, n = 10) or not (severe shock, n = 10) dopamine alone was able maintain mean arterial pressure >65 mm Hg.


METHODS
Dopamine was progressively withdrawn and replaced successively by norepinephrine and then epinephrine (the order of the two agents was randomly determined) to maintain mean arterial pressure constant (moderate shock) or to increase mean arterial pressure above 65 mm Hg (severe shock).


RESULTS
Systemic circulation (pulmonary artery catheter) and splanchnic circulation (indocyanine green dilution and hepatic vein catheter) and gastric mucosal Pco(2) (gas tonometry) were measured during dopamine (moderate shock only), norepinephrine, and epinephrine administration (both groups). Data were analyzed with nonparametric tests and are presented as median [percentiles 25-75]. In moderate shock, cardiac index was similar to dopamine and norepinephrine (3.1 [2.7-3.8] vs. 2.9 [2.7-4.1] L/min.m2, p = nonsignificant) but greater with epinephrine (4.1 [3.5-4.4] p <.01 vs. dopamine and norepinephrine). Splanchnic blood flow was similar with the three agents (732 [413-1483] vs. 746 [470-1401] vs. 653 [476-1832] mL/min.m, p = nonsignificant). The gradient between mixed-venous and hepatic venous oxygen saturations was lower with dopamine than with norepinephrine and epinephrine, but the Pco(2) gap was similar with the three agents. In severe shock, cardiac index was higher, but splanchnic blood flow was lower, with epinephrine than with norepinephrine (4.6 [3.7-5.3] vs. 3.4 [3.0-4.1] L/min.m2, p <.01 and 860 [684-1334] vs. 977 [806-1802] mL/min.m2, p <.05, respectively). Epinephrine increased the mixed-venous and hepatic venous oxygen saturation gradient but did not alter Pco(2) gap.


CONCLUSIONS
Dopamine and norepinephrine have similar hemodynamic effects, but epinephrine can impair splanchnic circulation in severe septic shock.
De Backer
Daniel
D
Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Route de Lennik 808, B-1070 Brussels, Belgium. ddebacke@ulb.ac.be
Creteur
Jacques
J
Silva
Eliézer
E
Vincent
Jean-Louis
JL
D000368:Aged; D018592:Cross-Over Studies; D004298:Dopamine / Q000494:pharmacology* / Q000627:therapeutic use; D004837:Epinephrine / Q000494:pharmacology* / Q000627:therapeutic use; D005260:Female; D005753:Gastric Mucosa / Q000187:drug effects; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D008297:Male; D008875:Middle Aged; D009638:Norepinephrine / Q000494:pharmacology* / Q000627:therapeutic use; D011446:Prospective Studies; D012772:Shock, Septic / Q000188:drug therapy*; D013152:Splanchnic Circulation / Q000187:drug effects*; D018709:Statistics, Nonparametric; D014662:Vasoconstrictor Agents / Q000494:pharmacology* / Q000627:therapeutic use
D014662:Vasoconstrictor Agents; D004298:Dopamine; D009638:Norepinephrine; D004837:Epinephrine