Does anyone use it?
Weingart says its bad and that there is really no use for it as there are superior alternatives.
Agree?
Weingart says its bad and that there is really no use for it as there are superior alternatives.
Agree?
Dopamine
- Thread starter tsbqb
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The data on individual pressors/inotropes is not very good.
In most cases starting with Levophed will work out fine.
Try to simply your algorithms in the ED.
If you are talking about true ICU medicine in the unit, maybe you have more time to experiment with multiple options.
In most cases starting with Levophed will work out fine.
Try to simply your algorithms in the ED.
If you are talking about true ICU medicine in the unit, maybe you have more time to experiment with multiple options.
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It was the go-to pressor for Peds according to the Peds sepsis guidelines; however, that's going to change after the recent double blinded RCT that came out of Brazil that demonstrated increased mortality (21% vs 7%) and health care associated infections in the dopamine group compared to the epi group. However, for some reason they didn't study levophed, as well. Several of my Peds EM attendings continue to use dopamine, despite this.
I still don't understand why we treat kids as some different species. For most cases, they really are "little adults", and given the adult literature and now this recent study, I have no idea why anyone would ever use dopamine as a vasopressor.
I still don't understand why we treat kids as some different species. For most cases, they really are "little adults", and given the adult literature and now this recent study, I have no idea why anyone would ever use dopamine as a vasopressor.
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I use it occasionally ( but not often, like maybe twice in the past year)
Never in sepsis
I have used it in cardiogenic shock, where the patient is completely fluid overloaded, and you need an inotrope so that you can get some fluid to the kidney's and then "squeeze the beans".
Although usually if I want a pure inotrope, I go with dobutamine over dopamine.
In my experience with symptomatic bradycardia, the patient either responds to a couple hits of atropine and then is fine, or we end up floating a pacer, so the dopamine is on for maybe 30-45 minutes. Although if anyone has any really cool bradycardia cases I love to hear about those.
Never in sepsis
I have used it in cardiogenic shock, where the patient is completely fluid overloaded, and you need an inotrope so that you can get some fluid to the kidney's and then "squeeze the beans".
Although usually if I want a pure inotrope, I go with dobutamine over dopamine.
In my experience with symptomatic bradycardia, the patient either responds to a couple hits of atropine and then is fine, or we end up floating a pacer, so the dopamine is on for maybe 30-45 minutes. Although if anyone has any really cool bradycardia cases I love to hear about those.
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I love listening to Scott Weingart's podcasts. However, he can sometimes come across as a bit obnoxious with his absolutism. Being an EM celebrity, he practices in a unique environment, yet he makes statements like this as if they are universally applicable.
There are many EDs around the country where a patient who needs pressors may have to wait 30 minutes for a central line because there is only one ED doc and multiple things are happening to multiple patients at the same time. There are also many EDs that prevent RNs from running any pressors except Dopamine through a peripheral IV. A lot of these are going to overlap. In that case you have 2 options:
1) Place an IO and run your pressor of choice through it.
2) Start dopamine to bridge till you have the time to place a central line.
We can argue back and forth about which option is preferable, but I think most people can agree that neither option is obviously much worse than the other. For me, dopamine is close to the bottom on my list of preferences. But I am not above using it in a pinch.
Dopamine has one nice advantage-- shelf stable at room temp already mixed in a sealed/foiled bag.
So it is frequently available in code carts, and you can have it up and hanging in <30s.
Not the worst temporizer while you fluid bolus and get levophed mixed properly and a pump and etc etc...
So it is frequently available in code carts, and you can have it up and hanging in <30s.
Not the worst temporizer while you fluid bolus and get levophed mixed properly and a pump and etc etc...
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Cool bradycardia stories?
Isoproterenol for the win.
Isoproterenol for the win.
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Give me a "dirty epi" drip any day. 1 mg in a liter of NS. Each 1 ml = 1 mcg epi (0.001mg).
I use it all the time as a push dose pressor as well. I have the nurse mix it up, then I pull off 20 cc at a time. Pushing it slowly, even after 20 cc, all you're giving is 0.02mg (20mcg) of epi... tiny doses. But it works wonders in things like anaphylaxis and borderline stable bradycardia. And you can just keep pushing 20mcg doses until you get the effect you want.
For the patient who is just ill and needs a pressor, "dirty epi drip" in a 1 liter bag and hang it open over an hour. Makes it easy. Let the drip calculations to the ICU folks upstairs.
I use it all the time as a push dose pressor as well. I have the nurse mix it up, then I pull off 20 cc at a time. Pushing it slowly, even after 20 cc, all you're giving is 0.02mg (20mcg) of epi... tiny doses. But it works wonders in things like anaphylaxis and borderline stable bradycardia. And you can just keep pushing 20mcg doses until you get the effect you want.
For the patient who is just ill and needs a pressor, "dirty epi drip" in a 1 liter bag and hang it open over an hour. Makes it easy. Let the drip calculations to the ICU folks upstairs.
Agree dirty epi also typically available on the code cart and can be up and running almost as quickly.
I have worked some places where staff refuses to help you set this up, refuses to run it until they check the hospital policy, mix-sheet, pump-dictionary and the on-call pharmacist... but they'll gladly hang wide-open dopa through an 20g in the ante cube. I think really the main advantage Dopa has is grandfathered familiarity amongst a wide audience-- like when you respond to a floor code, etc.
Its really a niche role now, eh?
I have worked some places where staff refuses to help you set this up, refuses to run it until they check the hospital policy, mix-sheet, pump-dictionary and the on-call pharmacist... but they'll gladly hang wide-open dopa through an 20g in the ante cube. I think really the main advantage Dopa has is grandfathered familiarity amongst a wide audience-- like when you respond to a floor code, etc.
Its really a niche role now, eh?
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The beauty of epi is, if I can mix it up and administer it myself if I had to. Grab a 1 mg off the code cart (1:10k or 1:1000, it doesn't matter), and inject it into a 1 L bag of saline. Shake. There it is! If you asked me literally to get any other drip and program it into a pump, Id stare at you dumbfounded like a lost puppy.
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Is dopamine being safer peripherally even true or just antiquated dogma?
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Dogma
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Levophed through a peripheral, especially if its a fat AC line. I also love the dirty epi.
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That's like one of those "if a tree falls in a forest..." questions. It doesn't matter if it's true if its accepted as dogma and your staff are uncomfortable doing it because it's against their protocols. Sure, you can fight to change things, educate your staff, get in on the pharm/med safety committee, negotiate with nursing leadership... But is this THE fight you want to spend your energy on? The answer is a definite NO for me.
I can McGuyver an epi drip too. But I need dopamine when I don't have time to place a central line right now because a bunch of other things are happening in the ED. If I don't have time for a central line, I don't really have time to mix/hang/pump/check the epi drip either. I do have time to say "hang the dopa".
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You can pull 1 cc of the cardiac epi (100mcg) into 9cc of saline, then you have 10mcg/ml of 1/100,000 epi, that can easily be pushed through a peripheral IV. 1-2cc at a time gives you 10-20mcg, every 3-5 minutes, which is what most epi drips run at.
Great for a little post intubation hypotension.
1mg in 1 L is faster, but then you have to push 10-20cc to get the same amount for push dose pressor, and the concentration is 1/1Million, which is very dilute.
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I have seen some research of late that levophed and epi can safely be administered through a PIV as long as the nurse does IV checks every hour. I was thinking about how to sign that out to the ICU
Step 1: Tell them you are running levophed through a peripheral IV, but it's ok because you read some research.
Step 2: Place phone 2 ft from ear, prepare for explosion
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Exactly. Again, you might be in the right, and if you consistently do this, explain yourself, share that paper on every sign out, then eventually the ICU folks may come around to it. But is that how I want to spend my energy?
I feel like each of us can have 1 issue we harp on. The particular pet peeve you are willing to fight for change over. More than one issue though and you become 'that guy'. I don't feel that the ability to run pressors through a PIV is worth it for me to make my one issue.
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Good point - picking a single issue at a time makes you "the guy who likes peripheral pressors", but start ripping off c collars, saying that droperidol does not mandate 4 hours of cardiac monitoring, advocating for ketamine in head-injured patients, etc and you'll come across as reckless.
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1) Readily available, premixed on every crash cart everywhere in the hospital (which matters if you are responding to a floor code or rotating on another service in residency, so can be hanged immediately after a verbal order. Other pressors often have to be mixed by and picked up from the pharmacy, making their decision-to-intravenous time much longer.
2) Commonly believed (whether fairly or not) to be relatively safe for use through a peripheral IV. It doesn't really matter that it is probably not that different from other pressors in terms of causing limb ischemia and sclerosing veins, this is the pressor that is least likely to cause an argument if you ask an RN to hang through a PIV.
3) There hasn't really been damning evidence that it is much worse than any of the other options. Even the increased arrhythmia risk is not SO compelling as to completely cross out the medication from your arsenal.
