Time to re-think the use of dobutamine in sepsis

Abstract

Dobutamine is commonly used worldwide and included in the protocol for early goal-directed therapy (EGDT). Since the use of dobutamine in EGDT was reported, it has been considered to be an important component, especially in the treatment of septic patients with myocardial dysfunction. However, it is questionable whether dobutamine improves the mortality of sepsis and septic shock.In three recent randomized controlled trials (ProCESS, ProMISe, and ARISE trials), the frequency of dobutamine use was significantly higher in the EGDT group than in the standard care group, but there were no significant differences in the mortality between the groups. These results suggested that dobutamine use may have been overemphasized despite its insignificant effect on the mortality in septic patients. Further, a propensity score analysis revealed that dobutamine use was associated with higher mortality in patients with septic shock.Although dobutamine leads to an increase in cardiac index, myocardial oxygen demand also increases, thus increasing the risk of myocardial ischemia and tachyarrhythmia. It is well known that the mortality in sepsis complicated with atrial fibrillation (AFib) is worse than that in sepsis without AFib. A propensity score-matched analysis reported that β-blockers were associated with better survival in patients with sepsis complicated with AFib. Further, a randomized controlled trial reported that a short-acting β-blocker improved the survival in patients with septic shock. These studies also indicated the risk of β-stimulation during sepsis.Notably, improvements in surrogate markers, such as CI, do not always indicate improvements in patient-centered outcomes, such as mortality. Conversely, some evidence indicates the worsening of patient-centered outcomes despite improvements in surrogate markers.Thus, available evidence suggests that the benefits of dobutamine in patients with sepsis are unclear, but its use might be harmful rather than beneficial, considering the beneficial effects of β-blockers in sepsis that have been reported in recent clinical studies. From this perspective, we will soon have to rethink regarding dobutamine use in patients with sepsis.

Prolonged Use of an Impella Assist Device in a Sepsis-Induced Cardiomyopathy: A Case Report

“…Current guidelines recommend the use of dobutamine for further ionotropic support (Grade 1C), but recent studies question its benefit [5,7]. Although dobutamine increases the cardiac index, it has not been shown to reduce mortality even in cases with severe heart failure (Ejection fraction <35%) [8]. One 2013 study suggested that it may even be associated with an increase in 90-day mortality [9].…”

Plasma neutrophil gelatinase-associated lipocalin and factors related to acute kidney injury and mortality in critically ill cancer patients

“…However, dobutamine increases cardiac output and splanchnic blood flow. In addition, dobutamine has not demonstrated a benefit in mortality and could even decrease survival [ 30 , 31 ].…”

Levosimendan and Global Longitudinal Strain Assessment in Sepsis (GLASSES 1): a study protocol for an observational study

“…Conversely, the use of beta-blockers in septic shock has been linked to an increase in survival rate in some studies. 10 …”

“…Conversely, the use of beta-blockers in septic shock has been linked to an increase in survival rate in some studies. 10 The use of levosimendan in cardiogenic shock during sepsis was first described in a 2005 case report. 11 Since then there have been small studies and other case reports that have shown better outcomes in terms of right and left ventricular contractility, ventricular coupling, cardiopulmonary performance, global oxygen and splanchnic perfusion when compared with dobutamine and placebo.…”