Septic shock dobutamine

An important overall approach for treatment of sepsis is goal-directed therapy. Mortality can be reduced by early placement and use of a central venous catheter, increased fluid volume administration, dobutamine therapy if needed, and red blood cell transfusion, to achieve specific physiologic goals in the first 6 hours. Evidence-based treatment recommendations for sepsis and septic shock from the Surviving Sepsis campaign are presented in Table 45-3. 

Dobutamine is widely used to increase myocardial contractility, cardiac output, and stroke volume in the peri-operative period. It is less likely to increase heart rate than dopamine. There is evidence that dobutamine can increase both myocardial contractility and coronary blood flow. This makes it particularly suitable for use in patients with acute myocardial infarction. Dobutamine is also suitable for treating septic shock associated with increased filling pressures and impaired ventricular function. Owing to the competing a and 3 activity there is usually little change in mean arterial pressure. 

A 46-year-old woman with septic shock had a peripheral venous infusion of vasopressin 0.04 U/minute in addition to dobutamine, via the subclavian vein extravasation of vasopressin to local soft tissue resulted in ischemic skin necrosis (26). 

Oj effects noradrenaline (with slight P effect on heart) is selectively released physiologically where it is wanted as therapeutic agents for hypotensive states (excepting septic shock) dopamine and dobutamine are preferred (for their cardiac inotropic effect). Also having predominantly effects are imidazolines (xylometazoline, oxymeta-... 

After adequate fluid resuscitation has been established, inotropic support is usually required. Noradrenaline is the inotrope of choice for septic shock its potent a-adrenergic effect increases the mean arterial pressure and its modest Pj effect may raise cardiac output, or at least maintain it as the peripheral vascular resistance increases. Dobutamine may be added further to augment cardiac output. 

Some clinicians use adrenaline, in preference to noradrenaline plus dobutamine, on the basis that its powerful a and p effects are appropriate in the setting of septic shock it may exacerbate splanchnic ischaemia and lactic acidosis. 

There are three clinical trials using phenylephrine in septic shock evaluating 38 patients. Phenylephrine (0.5 to 9 mcg/kg per minute), when used alone or in combination with dobutamine or low doses of dopamine, improves blood pressure and myocardial performance in fluid-resuscitated septic patients. Incremental doses of phenylephrine over 3 hours result in linear dose-related increases in MAP, SVR, heart rate, and stroke index when administered as a single agent in stable, nonhypotensive but hyperdynamic, volume-resuscitated... 

Martin C, Viviand X, Arnaud S, et al. Effects of norepinephrine plus dobutamine or norepinephrine alone on left ventricular performance of septic shock patients. Crit Care Med 1999 27 1708-1713. 

Duranteau J, Sitbon P, Teboul JL, et al. Effects of epinephrine, norepinephrine, or the combination of norepinephrine and dobutamine on gastric mucosa in septic shock. Crit Care Med 1999 27 893-900. 

Reinelt H, Radermacher P, Eischer G, et al. Effects of a dobutamine-induced increase in splanchnic blood flow on hepatic metabolic activity in patients with septic shock. Anesthesiology 1997 86 818-824. 

Seguin P, Bellissant E, Le Tulzo Y, et al. Effects of epinephrine compared with the combination of dobutamine and norepinephrine on gastric perfusion in septic shock. Clin Pharmacol Ther 2002 71 381-388. 

Zhou SX, Qiu HB, Huang YZ, et al. Effects of norepinephrine, epinephrine, and norepinephrine-dobutamine on systemic and gastric mucosal oxygenation in septic shock. Acta Pharmacol Sin 2002 23 654-658. 

---