peripheral dopamine

[charmcitygasman]

so we seem to be doing a lot of kidneys without central lines lately and it has come up a few times about giving "renal dose" dopamine if the kidney seems to be sluggish in function. I don't believe this has been proven to help but I have heard some anecdotal tales.

Anyways the question is would you all be comfortable giving this peripherally and monitoring for any signs of limb ischemia or would you want a central line. Also would the number of sticks to that patients arm make a difference (as in we had to stick the patient 4 times to get 2 big IVs and a few more times for an a line).

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[nap$ter]

as you've pointed out, renal dose dopamine doesn't change outcome, so I wouldn't ever do it for "sluggish" kidneys, even if I had a central line. there's also a chance of tachyarrythmia, even at "renal" doses.

given those relative contraindications, I would never give dopamine peripherally, and almost never give it centrally - there are cleaner options.

if you want more blood pressure, on the other hand, there are safer drugs for peripheral administration.

 

[Idiopathic]

low dose dopaine for renal function is ridiculous and probably dangerous.

however, in transplants who arent tolerating an anesthetic well, we use it preferentially over neo, etc. to hopefully allow for some increased RBF relative to the other agents

 

[sevoflurane]

Fluids/colloids for blood pressure in kidney transplants (the transplant surgeons I've worked with prefer this method). Kidneys are particularly sensitive to pressors. They don't like it.

Fenlodopam (not a vasoconstrictor) seems to have some promise for increasing renal blood flow + some protection. I dont think the jury is out on this one.

I don't like giving pressors through peripheral IV's... unless I'm coding someone.

 

[Idiopathic]

we volume load our tx to either a CVP of 12 or with 4 L of NS prior to cx-clamp so they definitely have adequate volume status, IMO

 

[DrMunkey]

There was a question on a similar topic on the ITE.

 

[SexPanther]

Blood transfusion is associated with improved graft survival due to the immunosuppressive effects.

 

[fakin' the funk]

There was a question on this topic on the ITE. Which of the following has been proven to have efficacy in improving graft outcome in donor kidney. Answer choices included Mannitol, Fenoldapam, Dopamine... I don't remember the other 2. My attendings post-exam state very matter of factly that it's fenoldapam... haven't bothered to look it up in addition to the other umpteen things I'm sure I missed.

As SexPanther said...pRBC tranfusion improves outcome, and this was one of the choices on the ITE question you mention.

I believe the other 4 were mannitol, furosemide, fenoldopam, dopamine.

Of those other 4 choices, I think fenoldopam is the least "controversial" in terms of being of potential benefit.

 

[Idiopathic]

There was a question on this topic on the ITE. Which of the following has been proven to have efficacy in improving graft outcome in donor kidney. Answer choices included Mannitol, Fenoldapam, Dopamine... I don't remember the other 2. My attendings post-exam state very matter of factly that it's fenoldapam... haven't bothered to look it up in addition to the other umpteen things I'm sure I missed.

the answer is dopamine when given to the donor prior to cross clamping...has been shown to reduce need for dialysis->improve graft longevity.

does NOT apply to recipient treatment with dopamine, however

 

[charmcitygasman]

Hmm, we use mannitol and lasix in all our transplants. I assumed that this is done because it improves graft outcome. Have to look up if its true. Is this not standard practice?

 

[deleted9493]

Yeah, most texts seem to talk about mannitol and that is our institutional practice, as well. It's not conclusive evidence but I think it was the best option of those listed for graft outcome in recipients.

 

[urge]

so we seem to be doing a lot of kidneys without central lines lately and it has come up a few times about giving "renal dose" dopamine if the kidney seems to be sluggish in function. I don't believe this has been proven to help but I have heard some anecdotal tales.

Anyways the question is would you all be comfortable giving this peripherally and monitoring for any signs of limb ischemia or would you want a central line. Also would the number of sticks to that patients arm make a difference (as in we had to stick the patient 4 times to get 2 big IVs and a few more times for an a line).

Sounds like the patient is going to be overnight or longer on dopamine through a peripheral IV. I wouldn't sign up for that. Chances are over so many hours the iv will get infiltrated. I could start the peripheral dopamine but I would put a central line as soon as the case is finished.

I don't see the need for 2 big IVs or a line. I have never seen a kidney transplant bleed out. An 18g is more than enough.

 

[SexPanther]

the answer is dopamine when given to the donor prior to cross clamping...has been shown to reduce need for dialysis->improve graft longevity.

does NOT apply to recipient treatment with dopamine, however

Answer is pRBC although what you say may be true (your answer isn't to the ITE ?). If it is, why aren't we giving the donor nephrectemy cases dopamine?

 

[Idiopathic]

yeah the data i cite above is from an 09 JAMA article so its unlikely to be in the ITE yet. The answer must be blood, since intravascular volume seems to be the most important predictor of graft success

i think if you look at it that way, it could also have been normal saline, CVP > 10, etc. anything that had to do with establishing good RBF

 

[DrN2O]

So do everybody get a unit of packed cell? I don't think so.

yeah the data i cite above is from an 09 JAMA article so its unlikely to be in the ITE yet. The answer must be blood, since intravascular volume seems to be the most important predictor of graft success

i think if you look at it that way, it could also have been normal saline, CVP > 10, etc. anything that had to do with establishing good RBF

 

[SexPanther]

yeah the data i cite above is from an 09 JAMA article so its unlikely to be in the ITE yet. The answer must be blood, since intravascular volume seems to be the most important predictor of graft success

i think if you look at it that way, it could also have been normal saline, CVP > 10, etc. anything that had to do with establishing good RBF

Nah bud, it's not about the volume (but volume is important for immediate graft function as you stated). It's about the immunosuppressive effects of pRBC that prolong graft survival.

Of course, not everybody gets blood. It was just a question asking which one has been shown to improve graft survival post-operatively, not immediate or delayed graft function.

I do believe that the evidence is very old (I think the original studies were from 1978 and 1980) and in the age of cyclosporine/tacrolimus not nearly as relevant or important. They have done several studies of donor specific blood transfusino preoperatively to treat anemia and the results were conflicting.

Of the answer choices given though, pRBC would have been the best choice.

 

[Idiopathic]

Im still not convinced by your explanation. I think its much more reasonable to explain that prevention of ischemia (i.e.hematocrit above 20) or renal blood flow is more valuable. all the other choices probably have as much data supporting them as does RBC transfusion with the goal of immune suppression

 

[fakin' the funk]

Nah bud, it's not about the volume (but volume is important for immediate graft function as you stated). It's about the immunosuppressive effects of pRBC that prolong graft survival.

Of course, not everybody gets blood. It was just a question asking which one has been shown to improve graft survival post-operatively, not immediate or delayed graft function.

I do believe that the evidence is very old (I think the original studies were from 1978 and 1980) and in the age of cyclosporine/tacrolimus not nearly as relevant or important. They have done several studies of donor specific blood transfusino preoperatively to treat anemia and the results were conflicting.

Of the answer choices given though, pRBC would have been the best choice.

This.

Y'know what SexPanther? 60% of the time, you're right every time.

 

[BLADEMDA]

http://www.ncbi.nlm.nih.gov/pubmed/16182714


http://www.theclinics.com/periodicals/atc/article/S0041-1345%2807%2900644-6/abstract


http://facm.unjbg.edu.pe/revistaspe...tical Care Medicine/Marzo 2006 [34(3)]/19.pdf

 

[BLADEMDA]

This.

Y'know what SexPanther? 60% of the time, you're right every time.

let's get the evidence.


http://journals.lww.com/transplantj...FACTORS_FOR_DELAYED_GRAFT_FUNCTION_IN.15.aspx


http://books.google.com/books?id=9d...rce=bl&ots=Mgkazw1p5Q&sig=_1sm5CM5AARNxJz59qK



Conclusions. DGF results in an approximately 10% higher rate of graft failure. DGF incidence can be reduced by the administration of mannitol during transplantation, which minimizes CIT and optimizes donor management. Grafts from multi-organ donors and kidney-only donors appear to be of equal quality.

 

[BLADEMDA]

PRBC transfusion results in a variety of immunomodulatory effects, often referred to as transfusion-associated immunomodulation. Numerous components of blood have been implicated as agents of transfusion-associated immunomodulation. Recent reviews8,9 of the immunomodulatory effects of blood provide extensive details on this topic. In support of earlier observations, in 1997 Opelz et al10 demonstrated a clear benefit of red cell transfusions on renal allograft survival in transplant recipients. With regard to the effect of transfusion on tumor recurrence and outcomes in cancer patients, meta-analyses have not yielded an answer to the question of whether transfusion increases the risk of death or tumor progression in these patients.11,12

 

[BLADEMDA]

Transplantation. 1997 Apr 15;63(7):964-7.
Prospective evaluation of pretransplant blood transfusions in cadaver kidney recipients.

Opelz G, Vanrenterghem Y, Kirste G, Gray DW, Horsburgh T, Lachance JG, Largiader F, Lange H, Vujaklija-Stipanovic K, Alvarez-Grande J, Schott W, Hoyer J, Schnuelle P, Descoeudres C, Ruder H, Wujciak T, Schwarz V.
Department of Transplantation Immunology, University of Heidelberg, Germany.
Abstract

BACKGROUND: A beneficial effect of pretransplant transfusions on graft survival was demonstrated in the early 1970s. In the mid-1980s, however, retrospective studies showed that transfusions had lost their graft-protective effect in the cyclosporine era. During the last 10 years, deliberate transfusion pretreatment of transplant patients has been discontinued. METHODS: Within a collaborative project of 14 transplant centers, prospective recipients of cadaver kidney grafts were randomized to receive either three pretransplant transfusions or transplants without transfusions. RESULTS; The graft survival rate was significantly higher in the 205 transfusion recipients than in the 218 patients who did not receive transfusions (at 1 year: 90+/-2% vs. 82+/-3%, P=0.020; at 5 years: 79+/-3% vs. 70+/-4%, P=0.025). Cox regression analysis showed that this effect was independent of age, gender, underlying disease, prophylaxis with antilymphocyte antibodies, and preformed lymphocytotoxins. CONCLUSIONS; Transfusion pretreatment improves the outcome of cadaver kidney transplants even with the use of modern immunosuppressive regimens

 

[Idiopathic]

well there you go

 

[fakin' the funk]

let's get the evidence.

You mean, copying and pasting bits and pieces of as many abstracts from Pubmed as you can find, without reading the original source material?

 

[Idiopathic]

(ssssh..its a funny bit)

 

[quickfeet]

Had a patient with post-operative hypotension develop new-onset Afib ~18 hours after starting a dopamine drip. I wanted to blame it on the dopamine, however, the hospitalists did not believe it to be the cause.

Won't get into all the details of the case, but waht i am wondering about is whether or not this garbage should even be used anymore given that it is known to be pro-arrhythmic

 

[Planktonmd]

I have never seen a patient develop limb ischemia because of peripheral Dopamine at any dose!

 

[nimbus]

Had a patient with post-operative hypotension develop new-onset Afib ~18 hours after starting a dopamine drip. I wanted to blame it on the dopamine, however, the hospitalists did not believe it to be the cause.

Won't get into all the details of the case, but waht i am wondering about is whether or not this garbage should even be used anymore given that it is known to be pro-arrhythmic

There is no perfect inotrope. Pick your poison.