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LETTERS TO THE EDITOR

Let Us Not Displace Small-Dose Dopamine from the Modern ICU So Soon

Department of Cardiac Surgery, Royal Liverpool Children’s NHS Trust (Alder Hey Hospital), Liverpool, United Kingdom

To the Editor:

I read with great interest the review article by Debaveye et al. (1). Although they presented the available scientific evidence to conclude that there is no longer a place for small-dose dopamine in the ICU, I still believe that their conclusion is a bit premature.

Before accepting the available evidence condemning small-dose dopamine, confounding factors must be taken into consideration. First, some patients may have inadequate volume resuscitation. Additionally, patients may already be receiving other pressor or inotropic agents that may have detrimental effects on renal and splanchnic perfusion. Moreover, studies that purport to measure splanchnic blood flow actually measure something else. Occasionally, regional inadequacies are generalized to be global impairments. Furthermore, as there are numerous differences between animals and humans that may confound interpretations of the results, results from animal studies should be interpreted with caution.

Since in the present era of evidence-based medicine, evidence from large randomized controlled trials or meta-analyses of multiple randomized trials is generally considered the best approach to ascertain the value of a particular therapy (2), my suggestion is that till the time we have robust evidence from meta-analyses of large randomized controlled trials let us not discard small-dose dopamine.

References

1. Debaveye YA, Van den Berghe GH. Is there still a place for dopamine in the modern intensive care unit? Anesth Analg 2004; 98: 461–8.[Abstract/Free Full Text]
2. Mack MJ, Duhaylongsod FG. Through the open door! Where has the ride taken us? J Thorac Cardiovasc Surg 2002; 124: 655–9.[Free Full Text]

Response

Department of Intensive Care Medicine, Catholic University of Leuven, Leuven, Belgium

In Response:

Raja et al. take the defense for small-dose dopamine and do not accept the available evidence for advising against the use small-dose dopamine in the ICU. We agree with these authors that extrapolating data from animal studies or from human studies measuring surrogate markers of outcome to the clinical practice should be done with great caution. It is exactly this kind of misinterpretation that has lead to the multiple doubtful recommendations for the use of small-dose dopamine in the past. However, a well-designed, large, prospective, randomized, placebo-controlled clinical trial has showed that small-dose dopamine does not prevent or reverse acute renal failure, nor does it improve outcome (1). In addition, two meta-analyses were performed very carefully and came to the same conclusion (2,3). Besides the lack of clinical efficacy, small-dose dopamine has multiple side effects, as revealed form well-controlled clinical studies (4). We thus conclude that there is sound scientific evidence that no longer justifies the use of small-dose dopamine in the ICU.

References

1. Bellomo R, Chapman M, Finfer S, et al. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 2000; 356: 2139–43.[Web of Science][Medline]
2. Kellum JA, Decker JM. Use of dopamine in acute renal failure: a meta-analysis. Crit Care Med 2001; 29: 1526–31.[Web of Science][Medline]
3. Marik PE. Low-dose dopamine: a systematic review. Intensive Care Med 2002; 28: 877–83.[Web of Science][Medline]
4. Van den Berghe G, de Zegher F. Anterior pituitary function during critical illness and dopamine treatment. Crit Care Med 1996; 24: 1580–90.[Web of Science][Medline]

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