Renal Dose Dopamine

[SilverStreak]

What do you guys think? Fact or myth? I've read literature and been in debates with people that the argument could go either way.

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[militarymd]

ANZICs trial.....leaves no question in my mind.

 

[UTSouthwestern]

Just as the myth of Levophed "Leave em dead" kills your kidneys, this is another myth that needs to be put to rest.

 

[SilverStreak]

Okay, I'm hearing more and more it is a myth. So my question is why do physicians still order it?

 

[SilverStreak]

ANZICs trial.....leaves no question in my mind.

Thanks Mil, I have to show this to everyone at work. We have a hard time finding hard science to back up our thoughts on topics like this. Where do you find all these good research studies? I'd probably ask you a lot less questions if I could get my hands on more stuff like this.

I noticed in the case at the beginning, it was a cabg patient with sbp 100's, cvp of 5. This is our typical scenario (I work in a SICU that is half hearts, half general surgeries). We have a 70 or 80 year old pt with history of hypertension, diabeties, prime candidates for renal insufficiency before surgery, they go have this major operation, spend time on pump, then come out to us. Understandably, surgery wants lower bp so they don't blow a graft. But they also want those kidneys to pee with bp that's 30-40 points lower than the patients baseline, so they're not being perfused very well. It's hard to make some of my collegues understand why we're having urine issues. When I say back off your gtts and let the bp run a little higher, I inevitably get "but the mean is 60", and I try to tell tham yeah but 70 or 80 is better, and they will half the time end up calling the surgeons and get an order for renal dopamine. Also, we don't give fluid resuscitation like we should in my oppinion. If you're trying to diurese, the kidneys can't pee what not in the vascular system.

 

[Idiopathic]

Also, we don't give fluid resuscitation like we should in my oppinion. If you're trying to diurese, the kidneys can't pee what not in the vascular system.

Im glad you said it, I was going to.

 

[militarymd]

Okay, I'm hearing more and more it is a myth. So my question is why do physicians still order it?

2 reasons:

1) don't know any better
2) there is some other reason for it.

 

[militarymd]

Thanks Mil, I have to show this to everyone at work. We have a hard time finding hard science to back up our thoughts on topics like this. Where do you find all these good research studies? I'd probably ask you a lot less questions if I could get my hands on more stuff like this.

I noticed in the case at the beginning, it was a cabg patient with sbp 100's, cvp of 5. This is our typical scenario (I work in a SICU that is half hearts, half general surgeries). We have a 70 or 80 year old pt with history of hypertension, diabeties, prime candidates for renal insufficiency before surgery, they go have this major operation, spend time on pump, then come out to us. Understandably, surgery wants lower bp so they don't blow a graft. But they also want those kidneys to pee with bp that's 30-40 points lower than the patients baseline, so they're not being perfused very well. It's hard to make some of my collegues understand why we're having urine issues. When I say back off your gtts and let the bp run a little higher, I inevitably get "but the mean is 60", and I try to tell tham yeah but 70 or 80 is better, and they will half the time end up calling the surgeons and get an order for renal dopamine. Also, we don't give fluid resuscitation like we should in my oppinion. If you're trying to diurese, the kidneys can't pee what not in the vascular system.

Couple of things..

Do not confuse the presence of urine in the foley bag with "renal function"...volume of urine..high or low does not correlate well with presence or absence of renal function......this is well documented in aortic surgery patients where you expect renal dysfunction after surgery...I don't have the references at hand, but look in any recent anesthesia textbook.

fenoldopam ......that is something being looked at....I don't know if it will help or not...but I suspect not...

Factors that I think truly affect renal function:

1) length of surgery
2) blood pressure
3) underlying disease
4) nephrotoxins that we give
5) adequate total body sodium

 

[SilverStreak]

Factors that I think truly affect renal function:

1) length of surgery
2) blood pressure
3) underlying disease
4) nephrotoxins that we give
5) adequate total body sodium

We definitely have numbers 1,2,3, and sometimes 4 in our patients. With regards to sodium in the body, I will be honest in that I don't have a good grasp on it. I think of it simplistically as sodium follows water, so if they're polyuric, they can become hyponatremic. Or, if they have a higher sodium, they'll retain water and not diurese. I also know the relation of the renin angiotensin pathway in regards to renal. Beyond that, I'll make an idiot of myself, so please clarify the sodium issue for me if you don't mind.

 

[militarymd]

We definitely have numbers 1,2,3, and sometimes 4 in our patients. With regards to sodium in the body, I will be honest in that I don't have a good grasp on it. I think of it simplistically as sodium follows water, so if they're polyuric, they can become hyponatremic. Or, if they have a higher sodium, they'll retain water and not diurese. I also know the relation of the renin angiotensin pathway in regards to renal. Beyond that, I'll make an idiot of myself, so please clarify the sodium issue for me if you don't mind.

When I say "sodium"...I'm referring to isotonic crystalloid solutions. One of the only thing that consistently prevents renal dysfunction as a part of systemic inflammation (SIRS) is isotonic crystalloid administration......I don't like to use the word "volume" because that is not specific...it can mean albumin, prbc, ffp, platelets, etc.....the one thing that consistent protects the kidney is "isotonic crystalloid" .....some sodium concentration between 125 to 150 meq/liter.

 

[SilverStreak]

When I say "sodium"...I'm referring to isotonic crystalloid solutions. One of the only thing that consistently prevents renal dysfunction as a part of systemic inflammation (SIRS) is isotonic crystalloid administration......I don't like to use the word "volume" because that is not specific...it can mean albumin, prbc, ffp, platelets, etc.....the one thing that consistent protects the kidney is "isotonic crystalloid" .....some sodium concentration between 125 to 150 meq/liter.

Ah, now I see. I thought you were referring to serum sodium. I understand with the SIRS. If we're talking a heart pt on pump and the RBCs are getting hemolized going through pump, what do you think about drugs like Trasylol as well? I've had some who like it because it is supposed to offset this inflammatory response, but others who hate it because pt can have a bad reaction to it. And, while I'm asking, what's your take on Protamine for heparinized pump blood, for the same reasons as above?

 

[UTSouthwestern]

You can forget about Corlopam/fenoldapam. What little benefit it might provide toward renal arterial dilation is more than offset by systemic hypotension and subsequent decreased renal perfusion pressures.

 

[militarymd]

Ah, now I see. I thought you were referring to serum sodium. I understand with the SIRS. If we're talking a heart pt on pump and the RBCs are getting hemolized going through pump, what do you think about drugs like Trasylol as well? I've had some who like it because it is supposed to offset this inflammatory response, but others who hate it because pt can have a bad reaction to it. And, while I'm asking, what's your take on Protamine for heparinized pump blood, for the same reasons as above?

I'm pretty sure aprotinin is OUT.....This made CNN.

NEJM link

 

[militarymd]

You can forget about Corlopam/fenoldapam. What little benefit it might provide toward renal arterial dilation is more than offset by systemic hypotension and subsequent decreased renal perfusion pressures.

Is there a published trial demonstrating this?

I haven't kept up on what's out there for fenoldapam

 

[coccygodynia]

I'm pretty sure aprotinin is OUT.....This made CNN.

NEJM link

Wow. I was just talking to one of our perfusionists today and all of his pump patients get aprotinin. Its also used with one of the pediatric orthopods for scoliosis repair. Thanks for the link.

 

[SilverStreak]

You can forget about Corlopam/fenoldapam. What little benefit it might provide toward renal arterial dilation is more than offset by systemic hypotension and subsequent decreased renal perfusion pressures.

We've had a patient on it recently. The pt was hypertensive in spite of everything we were giving her and poor renal function as well. I'll agree it may not be a good drug choice for the general patient population, but in some patients it may be well tolerated and useful.

What do you guys think about AVP/aquaresis, any of you tried it?

 

[SilverStreak]

I'm pretty sure aprotinin is OUT.....This made CNN.

NEJM link

I had forgotten about this study someone had mentioned. We have a surgeon who won't let his patients have it for this very reason. It has not been duplicated yet though has it? I think I recall someone saying there was still question about how reliable one study it. But I would think the New England journal of Medicine would be pretty hard core on their research. I'm not up on the latest and greatest research on this type of stuff, but if there's any question, I would think it better to err on the side of caution and not use it. Most of our surgeons do use it, we had one order it as a continuous infusion for 4 hours post op on a cab (ironically enough it was the patient in my paralytics post), so it makes a light go off in my head.

 

[militarymd]

We've had a patient on it recently. The pt was hypertensive in spite of everything we were giving her and poor renal function as well. I'll agree it may not be a good drug choice for the general patient population, but in some patients it may be well tolerated and useful.

What do you guys think about AVP/aquaresis, any of you tried it?

AVP?

 

[UTSouthwestern]

AVP?

Arginine Vasopressin I'm guessing? For SIADH mediated hyponatremia, there are good outcomes by report, but not for renal vascular disease or vasoconstriction causing decreased perfusion pressures.

 

[SilverStreak]

Arginine Vasopressin I'm guessing? For SIADH mediated hyponatremia, there are good outcomes by report, but not for renal vascular disease or vasoconstriction causing decreased perfusion pressures.

Yes, I was reading an article that talked about the imbalance of AVP, but you're right it is connected to hyponatremia. It was just wondering because we see hyponatremia fairly frequently, and I have never heard any of our physicians mention it, I didn't know if it was a new type of treatment,

 

[militarymd]

In SIRS related hypotension, endogenous vasopressin levels are inappropriately low...1 to 10 picogram/ml vs near 100 pg/ml like it is supposed to be, so it makes physiologic sense to run low dose infusions to support the level....I don't remember the author...

There is been a series of articles looking at VAsopressin in septic shock...however, there is fear of mesenteric hypoperfusion....I've been using vasopressin 2.5 u/hr for the last years in patients with vasopressor resistant septic shock....with very good results.

In the GI literature for patients with cirrhosis and hepatorenal syndrome, vasopressin and vasopressin analogs have been demostrated to improve renal perfusion......

As for hyponatremia....yes, it is very common in critically ill patients. That's all I have to say about that.

 

[SexPanther]

The March issue of JCCM has research showing that Dopamine increases mortality in shock compared to other vasopressors. I don't have the article in front of me, so I can't list the pressors used or the inclusion criteria etc.

Assuming the above study holds up, and the knowledge that renal dose dopamine is a myth, why is it still being used? Aren't there better agents available now?

I'm interested to hear how it is used at various institutions. Thanks.

 

[Bobblehead]

Assuming the above study holds up, and the knowledge that renal dose dopamine is a myth, why is it still being used? Aren't there better agents available now?

People trained using it and old habits die hard. It's also premixed while everything else needs to be mixed which can be an interesting experience depending on where/when you're requesting another vasopressor..

 

[UTSouthwestern]

In SIRS related hypotension, endogenous vasopressin levels are inappropriately low...1 to 10 picogram/ml vs near 100 pg/ml like it is supposed to be, so it makes physiologic sense to run low dose infusions to support the level....I don't remember the author...

There is been a series of articles looking at VAsopressin in septic shock...however, there is fear of mesenteric hypoperfusion....I've been using vasopressin 2.5 u/hr for the last years in patients with vasopressor resistant septic shock....with very good results.

In the GI literature for patients with cirrhosis and hepatorenal syndrome, vasopressin and vasopressin analogs have been demostrated to improve renal perfusion......

As for hyponatremia....yes, it is very common in critically ill patients. That's all I have to say about that.

Our institution was involved in a multicenter study centering on mesenteric perfusion, septic shock, and vasopressin. They correlated hypoperfusion with decreased pH from tissue samples taken from the small bowel throughout the course of use a variety of vasopressors. Vasopressin did show a propensity to decrease the pH of the tissue samples which the investigators correlated to hypoperfusion.

The use of low infusion doses (0.5-2.5 U/h) did not seem to significantly alter tissue pH levels, however, so low doses appear to be a safe choice to use. From my perspective, if the patient faces death versus some dead bowel, choose dead bowel and give them a fighting chance.

 

[lawdawg]

People trained using it and old habits die hard. It's also premixed while everything else needs to be mixed which can be an interesting experience depending on where/when you're requesting another vasopressor..

This is the exact reason Dop is the initial vasopressor of choice at my institution, for nothing more than convenience.

 

[toughlife]

ANZICs trial.....leaves no question in my mind.

have a link to this?

 

[Bobblehead]

have a link to this?

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=11191541&dopt=Abstract

 

[militarymd]

This is the exact reason Dop is the initial vasopressor of choice at my institution, for nothing more than convenience.

Don't confuse using dopamine as a vasopressor vs as a renoprotective agent....there is a difference.

I believe SCCM still recommends dopamine or norepinephrine as acceptable first line vasopressors in sepsis.

 

[Sugar72]

Don't confuse using dopamine as a vasopressor vs as a renoprotective agent....there is a difference.

I believe SCCM still recommends dopamine or norepinephrine as acceptable first line vasopressors in sepsis.

I had an ICU attending tell me yesterday that a study came out in the NEJM in 2005 that said there is mortality benefit of using vasopressin as your initial pressor in septic shock. Now I spent about 2 hours looking for any article that said that in any journal. She is pulling my leg right? Should I mention that she is one of those people that always has to find something wrong with everything you do and everything you say!

 

[militarymd]

I had an ICU attending tell me yesterday that a study came out in the NEJM in 2005 that said there is mortality benefit of using vasopressin as your initial pressor in septic shock. Now I spent about 2 hours looking for any article that said that in any journal. She is pulling my leg right? Should I mention that she is one of those people that always has to find something wrong with everything you do and everything you say!

Have her give you the article.

 

[Bobblehead]

I had an ICU attending tell me yesterday that a study came out in the NEJM in 2005 that said there is mortality benefit of using vasopressin as your initial pressor in septic shock. Now I spent about 2 hours looking for any article that said that in any journal. She is pulling my leg right? Should I mention that she is one of those people that always has to find something wrong with everything you do and everything you say!

A quick google search turns up this link:
http://www.globalrph.com/vasopressin_shock.htm

Submitted without comment because I have not done a careful review of vasopressor recommendations for shock in a while so I can't speak for the quality of the studies in that link.

 

[cchoukal]

Arginine Vasopressin I'm guessing? For SIADH mediated hyponatremia, there are good outcomes by report, but not for renal vascular disease or vasoconstriction causing decreased perfusion pressures.

There was a really good science review in NEJM a couple years ago about vasopressin in ARF (in this case, from sepsis). I think the crux of it was that norepinephrine had a propensity to constrict, in addition to systemic arteries, the afferent arteriole, thereby decreasing GFR. In contrast, vasopressin has a higher affinity for the EFFerents, thereby raising GFR along with systemic MAP. In my own MICU experience, it seems like a good adjunct to other pressors, particularly NE, which I'd expect based on the underlying cellular mechanism, but I can't say I've noticed any difference in renal dysfunction.

The link is here:

http://content.nejm.org/cgi/reprint/351/2/159.pdf

But it's proprietary, so I'm not sure if it will take you to the article. Go to nejm.org and search "acute renal failure septic shock."

 

[SilverStreak]

Don't confuse using dopamine as a vasopressor vs as a renoprotective agent....there is a difference.

I believe SCCM still recommends dopamine or norepinephrine as acceptable first line vasopressors in sepsis.

The Critical Care Medical Society recommends Norepi as the initial pressor in septic shock. The golden hour treatment in sepsis has a pathway to follow for treatment and recommends clusters of treatment- cortisol therapy, intense insulin control, fluids, etc. Dopamine is not usually second line for us, we'll go to vasopressin after levophed if we're not keeping a pressure, Dobutrex is also recommended, but I can't remember the criteria off the top of my head. Xigris also needs to be up there on the list if we're going to treat aggressively and effectively. Sometimes, depending on the stage of sepsis, the cycle is too far gone for any treatment to reverse.

 

[militarymd]

The Critical Care Medical Society recommends Norepi as the initial pressor in septic shock. The golden hour treatment in sepsis has a pathway to follow for treatment and recommends clusters of treatment- cortisol therapy, intense insulin control, fluids, etc. Dopamine is not usually second line for us, we'll go to vasopressin after levophed if we're not keeping a pressure, Dobutrex is also recommended, but I can't remember the criteria off the top of my head. Xigris also needs to be up there on the list if we're going to treat aggressively and effectively. Sometimes, depending on the stage of sepsis, the cycle is too far gone for any treatment to reverse.

Are you sure? Read the 2004 update again.

Practice Parameters for Hemodynamic Support

 

[Idiopathic]

Are you sure? Read the 2004 update again.

Practice Parameters for Hemodynamic Support

Thats exactly what it says mil. We read this in IM last year, I think. Dopamine and levophed are the initial pressors of choice, after a trial of fluid therapy.

 

[Idiopathic]

Xigris also needs to be up there on the list if we're going to treat aggressively and effectively.

I want to believe in this, but I also wanted to believe in Trasylol too.

 

[UTSouthwestern]

I want to believe in this, but I also wanted to believe in Trasylol too.

The Trasylol reps are pushing a new article that is a psudo meta-analysis of Trasylol papers that supposedly refutes the findings of Mangano's paper.

Another large multicenter trial that will include data on morbidity with Trasylol use will be presented at the SCA.

 

[Idiopathic]

The Trasylol reps are pushing a new article

At $1K a bottle, I bet they are.

 

[Dr.MISHKA D.O.]

I have a question....

Why is Idiopathic so good at passing gas and so bad at everything else.......discuss amongst yourselves and get back to me.

Good luck at Vandy....go commies!

The Mish

 

[UTSouthwestern]

At $1K a bottle, I bet they are.

It's $540.00 for the 200 cc bottle, $270.00 for the 100 cc bottle, cheaper if you make a deal with Bayer. If your institution is paying $1K a bottle, their getting ripped.

 

[Idiopathic]

It's $540.00 for the 200 cc bottle, $270.00 for the 100 cc bottle, cheaper if you make a deal with Bayer. If your institution is paying $1K a bottle, their getting ripped.

Maybe its just cheaper in Texas Thats just what I was told by an attending. He obviously was exaggerating.

 

[militarymd]

There is actually very little incentive for Bayer to push Trayslol.


It is a very low profit drug for the company. To the uniformed, it may seem to be expensive, and a big money maker for Bayer, but the reality is that Trayslol makes up such a ting market share of all the drugs Bayer makes that it needs to cost a lot of money just to cover the manufacturing costs.

Just think about how much Traysol is used....Total number of CABGs per year.....what fraction of those cases get traysol?

Now compare that to say...some antihypertensive drug that a patient has to take every day for the rest of his life???

 

[UTSouthwestern]

There is actually very little incentive for Bayer to push Trayslol.


It is a very low profit drug for the company. To the uniformed, it may seem to be expensive, and a big money maker for Bayer, but the reality is that Trayslol makes up such a ting market share of all the drugs Bayer makes that it needs to cost a lot of money just to cover the manufacturing costs.

Just think about how much Traysol is used....Total number of CABGs per year.....what fraction of those cases get traysol?

Now compare that to say...some antihypertensive drug that a patient has to take every day for the rest of his life???

Trasylol also comes off patent in a couple of years.

 

[Noyac]

How about the renal failure, MI and strokes with traylol. I rarely used it in hearts. If we needed something it was, aminocaproic acid or tranexamic acid.

 

[Idiopathic]

Just think about how much Traysol is used....Total number of CABGs per year.....what fraction of those cases get traysol?

looks to me like thats even more incentive to push the drug. i mean, look at the total # of CABG's per year.

 

[sdn1977]

Agree with most stated opinions on the cost issue, but for a different reason. Trasylol is an expensive drug, but relative to drugs used in the OR/ICU it is not out of line with many of the others. As Mil pointed out, usage is low, so the monetary outlay the institution makes overall evens out, especially when you factor in the costs of other drugs which may be bundled into purchasing.

The price a drug is set at more reflects the cost of development, marketing and in this situation, potential lawsuits, rather than manufacturing costs which are very low unless it requires unique equipment.

The FDA issued a warning on Trasylol in Feb of this year about the potential renal failure. There are some who would like it removed from the market, but so far there has not been significant enough information to warrant that. Altho its been under patent for 13 years (drug patents are 17 years), generic manufacturers will wait to see if the legal issues develop before they jump into the market. The renal failure issue, IMO, is the reason for the Phase III trials on its use in spinal surgery since these folks are generally a healthier group than CABG pts.

(Sorry....I'm sure this is wayyyy off the original topic!)

 

[militarymd]

looks to me like thats even more incentive to push the drug. i mean, look at the total # of CABG's per year.

Look beyond just the OR.....how many patients get treated for a variety of medical conditions that don't come to the OR.

In the grand scheme of things.....traysolo is a low use, low profit drug.....EVEN if it were used on every single heart.

Drug companies make money on drugs that are used by many patients ...example would be hypertension or diabetes....

and who need the drugs every day for the rest of their life....

Not something like Traysolol.....limited patient population....single use.

 

[Idiopathic]

I agree, but if there werent potential profit to be made, no one would develop the drug (save for those few 'special exemption' drugs). I agree it isnt as profitable as Norvasc was, or as Diovan is now, but its all relative. If you fill a niche (as aprotinin attempted to do), there is money to be made.

 

[dogbone65]

But the point is, and a valid one, is that yes there are thousands of cabg's done every year but only a small fraction of them get traysolol.

 

[Idiopathic]

But the point is, and a valid one, is that yes there are thousands of cabg's done every year but only a small fraction of them get traysolol.

Im not sure I would agree with that. In fact, at every teaching hospital Ive seen the last three years (only 3...) every CABG I saw got trasylol. There may be a big diff in pp vs. academics, but I havent seen a pump case in the past year where it wasnt used