Dopamine For Mac
Chemical structure References Location of Dopamine/ Target tissues Dopamine is a neurohormone that is released by the hypotalamus. Dopamine What is Dopamine? Addictions/Disorders Using drugs enhances levels of dopamine A chemical in your brain that affects your emotions, movements and your sensations of pleasure and pain.
BACKGROUND: Depletion of central nervous system catecholamines, including dopamine, can decrease MAC (the minimum alveolar concentration of an.
(Reward-motivated behavior) Used by the brain to stimulate motivation and gives the body a sense of reward Produced in several areas of the brain, however the main region that holds dopamine is the substantia nigra Used as medication, acts on the sympathetic nervous system. Application of dopamine leads to increase heart rate and blood pressure Dopamine is needed for some brain diseases such as Parkinson's disease and doparesponsive dystonia Dopamine functions as a neurotransmitter, a chemical released by nerve cells to send signals to other nerve cells Most types of reward increase the level of dopamine in the brain A variety of addictive drugs increase dopamine neuronal activity. Schizophrenia involves highly altered levels of dopamine activity google images Molecular Formula: C8H11NO2 Function and Site of synthesis Site of storage Target tissue.
AIM: To determine if dopamine is effective in treating neonatal hypotension and safe to use comparing to other inotropes. METHODS: This is a review of evidence on inotropic treatment of neonatal hypotension. Databases searched were MEDLINE and the Cochrane Library, a total of 134 studies were identified. Only studies with high quality evidence (level 1a and b and 2a) were included.
After review, only eight studies were included in the final analysis. Pooled risk ratios derived for each outcome Mantel-Haenzel (M-H) fixed effect with CI, as reported in the Cochrane reviews were plotted in forest plot form. RESULTS: Eight articles met inclusion criteria, which all included treatment in preterm infants. Dopamine increased mean arterial blood pressure (BP) ( n = 163; r = 0.88, 95%CI: 0.76 to 0.94) and systolic BP ( n = 142; r = 0.81, 95%CI: 0.42 to 0.94) comparing to placebo. Dopamine has been shown overall to be statistically more effective in increasing BP than dobutamine ( n = 251, r = 0.26, 95%CI: 0.20-0.32).
However there were no differences in short term outcomes (periventricular leucomalacia, periventricular haemorrhage) and mortality between both drugs. There is no statistical evidence of dopamine being more effective than adrenaline or corticosteroids. There was no difference in morbidity and mortality outcomes when dopamine was compared to hydrocortisone (RR 1.81, 95%CI: 0.18 to 18.39) or adrenaline. CONCLUSION: In preterms, dopamine is the most studied drug, and we suggest it could be used as first line treatment in hypotension. Core tip: Hypotension is a common feature in the preterm infant.
The aim of this systematic review was to determine, after review of evidence, if dopamine would make a good first line drug therapy for hypotension in the neonatal population. Dopamine was shown across trials to increase blood pressure more effectively than dobutamine. There was no difference in morbidity and mortality outcomes when dopamine was compared to hydrocortisone or adrenaline. In preterm infants, dopamine is the most studied drug, and in general safer than others to use, we therefore cautiously suggest it could be used as first line treatment in hypotension. INTRODUCTION Hypotension is a problem frequently encountered on the neonatal intensive care unit. It is more common in preterm infants. The prevalence is said to be up to 45% in infants with a birth weight.
Antivirus report for safari12.0highsierraauto.pkg. Search terms and strategies The search was done in February 2015. The following MeSH terms were used: “Hypotension” (major), “Dopamine” (explode), “Dobutamine” (explode), “Hydrocortisone” (explode), “epinephrine” (explode), “norepinephrine” (explode). Results were limited to “Human” and “Age Group Newborn Infant birth to 1 mo”. The following results were obtained with Medline search: Hypotension (Major) AND Dopamine (explode) - 56 results Hypotension (Major) AND Dobutamine (explode) - 23 results Hypotension (Major) AND Epinephrine (explode) - 16 results Hypotension (Major) AND Norepinephrine (explode) - 3 results Hypotension (Major) AND Hydrocortisone (explode) - 36 results The search gave us a total of 134 articles.
After the duplicates were removed, there were a total of 86 articles. Study selection All titles and abstracts were read by 2 independent reviewers. Inclusion criteria applied were: Levels of evidence 1a, 1b and 2a (Table ). All abstracts were read and screened, and only the ones with a high level of evidence were kept. After this screening process, 22 studies were noted to be irrelevant to our question, and 56 did not qualify as level 1 or 2 evidence (16 observational studies, 10 review articles, 10 letters, 3 retrospective studies, 12 already included in Cochrane reviews, 4 case reports, 1 on-going randomised control trial) (For PRISMA flow chart of study selection, Figure ).
Dopamine effect on BP A recent meta-analysis by Sassano-Higgins et al showed that dopamine increases BP significantly in the hypotensive preterm infant and that it has a greater efficacy than other forms of therapy. In this review, after looking at 26 studies, whether random or fixed effect meta-analysis, it was found that there was a significant association between administrating dopamine and treatment success. Dopamine increased mean arterial BP (12 studies; n = 163; r = 0.88, 95%CI: 0.76 to 0.94) and systolic BP (8 studies; n = 142; r = 0.81, 95%CI: 0.42 to 0.94). All the 12 studies were prospective case series without any controls examining the treatment success of dopamine.
Dopamine vs dobutamine Dobutamine is a synthetic catecholamine which acts essentially on beta receptors, creating an adrenergic effect. Dobutamine is the second most commonly used inotrope to treat hypotension in the preterm infant; it is thought to have the same benefits as dopamine but without the peripheral vasoconstrictive effect.
Three articles containing trial data on a comparison of dopamine and dobutamine were identified. The Cochrane review by Subhedar et al compared dopamine and dobutamine. The main aims of this review were: Comparing the effectiveness of the treatment in reducing mortality and long-term outcomes (neurodevelopmental outcome at 2 years), in reducing the incidence of adverse neuroradiological sequelae (severe periventricular haemorrhage and/or periventricular leucomalacia), increasing systemic arterial BP and/or cardiac output, and to compare the frequency of adverse effects between both drugs. A total of 5 randomised control trials were included, with a total of 209 infants. Comparing dopamine vs dobutamine, there was neither a difference in mortality (RR 1.17, 95%CI: 0.47 to 2.92; RD 0.02, 95%CI: -0.12 to 0.16), nor in the incidence of periventricular leucomalacia (RR 0.43, 95%CI: 0.12 to 1.52; RD -0.08, 95%CI: -0.19 to 0.04), or in the incidence of grade 3 or 4 periventricular haemorrhages (RR 0.73, 95%CI: 0.15 to 3.50; RD - 0.02, 95%CI: -0.13 to 0.09), or in the incidence of tachycardia (RD -0.06, 95%CI: -0.25 to 0.14) (Figure ). No studies looked at the long-term neurodevelopmental outcome.
In treating hypotension, dopamine was more successful than dobutamine as evident from a significantly reduced risk of treatment failure (RR 0.41, 95%CI: 0.25 to 0.65). LVO was analysed in one paper in the Cochrane review.
Initially the raw numbers showed a drop in LVO with dopamine, compared to a rise in LVO with dobutamine. However the Cochrane review excluded this outcome from the analysis as the calculation of absolute changes was not possible. The authors concluded that dopamine was more effective than dobutamine in the short-term treatment of hypotension. As there were no statistical differences in long term outcomes and safety, no firm recommendations could be made. The meta-analysis by Sassano-Higgins et al mentioned in the above paragraph on dopamine and its effects on BP, contained a subgroup analysis where dopamine was compared with dobutamine. Dopamine administration was associated with a significantly greater overall efficacy for increase in BP than dobutamine (7 studies; n = 251; r = 0.26; 95%CI: 0.20 to 0.32).
There were no statistically significant differences in adverse neurological outcomes between dopamine and dobutamine. This meta-analysis contained two additional studies in addition to the five studies included in the Cochrane review by Subhedar et al (2003).
The latter excluded the study by Miall-Allen et al (1989) because it was a non-randomised study reporting the effect of addition of dobutamine in hypotensive preterm infants who did not respond to dopamine. Furthermore, it was a prospective case control study. Filippi et al’s primary objective was endocrine effects of dopamine and dobutamine. This study did not meet the inclusion criteria for a Cochrane review. Short-term improvement in BP was analysed in the Cochrane review, looking at 4 articles with successful treatment of hypotension. Each article looked at individually, concluded in an increase of BP.
A pooled estimate was not done regarding short-term effect on BP with both drugs in view of the variation in measuring and reporting BP in the included studies. However, in the meta-analysis, pooled analysis of the 7 studies ( n = 251, r = 0.26, 95%CI: 0.20-0.32) showed that dopamine had a greater efficacy in increasing the BP compared to dobutamine. However, dopamine is also thought to have endocrine adverse effects. Indeed exogenous dopamine infusion suppresses PRL, thyroid stimulating hormone (TSH) and T4 secretion by acting on specific dopamine D2 receptors.
It is believed that in preterm infants, unlike in adults, dopamine crosses the blood brain barrier and exerts its effects directly at the hypothalamic level as well as on the dopamine receptor trophic cells. Filippi et al’s study, which was not included in the Cochrane review, compared the endocrine effects between dopamine and dobutamine in VLBW, in a randomised prospective trial published in 2007. Thirty-five hypotensive infants were randomised into 2 groups, whether they received dopamine or dobutamine for hypotension after 2 boluses of crystalloid. In the group of infants treated with dopamine, levels of TSH, total thyroxine (T 4), prolactine (PRL), and growth hormone (GH) were significantly reduced after 12 h, comparing to the dobutamine group ( P.
Dopamine vs adrenaline Adrenaline = Epinephrine (EP) is a potent inotrope, and chronotrope, which acts on alpha and beta-receptors. It acts as a systemic and pulmonary vasodilator in low doses, and when doses are increased, it increases systemic pressure more than pulmonary pressure. Three articles were identified comparing adrenaline and dopamine: Two randomised controlled trials and one Cochrane review. In 2005, the randomised control trial by Valverde et al compared 2 groups of preterm infants 28 wk).
A randomised control trial in 2006 by Valverde et al compared 2 groups of preterm infants. Dopamine vs steroids Glucocorticoids increase vascular tone and myocardial contractility by increasing responsiveness to circulating catecholamines. In preterm infants, immaturity may also lead to limited adrenal reserves, being one the causes of low BP, therefore the use of steroids as treatment for hypotension is logical. In daily clinical practice, steroids are usually used for refractory hypotension. One Cochrane review analysed the effect of steroids in neonatal hypotension. The population targeted is the preterm infant. Hydrocortisone is the most common steroid used in the treatment of neonatal hypotension.
The Cochrane review by Ibrahim et al included, in addition to the comparison of corticosteroids vs placebo, also a comparison of steroids with dopamine. The primary objective was to investigate the effect of corticosteroids as a primary treatment of hypotension, and the secondary outcome was to look at benefits or adverse effects of steroid therapy (mortality, IVH grade 3 or 4, periventricular leukomalacia, chronic lung disease in surviving infants, necrotizing enterocolitis, bacterial sepsis). The population studied was all preterm infants. All inotropes There was one high-level evidence paper comparing different inotropes: A systematic review by Dempsey et al in 2007. One of the aims of the article was to compare the effectiveness of different inotropes. Pubmed search was performed looking for studies comparing 2 interventions, and seeking important clinical outcomes (survival, brain or lung injury, long-term neurodevelopmental outcome). Only randomised control trials in hypotensive preterm infants were included.
This systematic review compared dopamine with other inotropes. In the comparison with dobutamine, only articles already included in Subhedar’s Cochrane review were found, and concluded the same as above: Dopamine is more likely to increase BP than dobutamine. Four further studies were identified comparing dopamine to other inotropes regarding blood flow, which was irrelevant to our question, but showed that dopamine decreased LVO. Some studies were identified reporting a comparison of dopamine and adrenaline, but there was little evidence to support the use of this drug according to this review (2 studies). The authors concluded that there are many small studies addressing short-term effects of various catecholamines on physiological variables, but that there is no evidence regarding clinically important outcomes. DISCUSSION Even though various inotropes are used, Dopamine still seems to be the one which is most commonly prescribed in hypotension in all infants, including VLBW infants.
We looked at the evidence supporting the usage of dopamine and summarized this in Table. In this review, we wanted to determine whether dopamine could be used as a first line therapy. By definition, a first line therapy should be effective, safe to use with minimal side effects and easily available. Having a standardised approach to hypotension would make practice more homogeneous; this has its advantages and inconveniences. A universal initial approach allows one to start treatment and then consider other options according to the underlying pathology. In treatment of hypotension, there is no evidence to support the use of volume expansion, whether saline, or albumin,. Dopamine has been shown overall to be statistically more effective in increasing BP and with less treatment failure than dobutamine, There is no statistical evidence of dopamine being more effective than adrenaline or corticosteroids.
There were no papers of high evidence looking at treatment of hypotension with noradrenaline. Nevertheless, adrenaline has been shown to have more side effects than dopamine by increasing lactate, blood sugars, and lowering base excess. There is not enough evidence regarding mid and long term outcomes to support the usage of hydrocortisone as a first line drug. The meta-analysis by Higgins et al showed that hydrocortisone successfully increases BP.
This article was not included in our review, as it did not compare steroids to other inotropes. Antenatal steroids are believed to have a positive effect on low BP in the preterm infant. Title of study Study group Study type (evidence) Outcome Key result Comment All inotropes Dempsey et al Treating hypotension in the preterm infant: When and with what: a critical and systematic review Preterm infant Critical systematic review Which preterm may benefit from treatment and with what intervention 17 studies reviewed.
No threshold BP that was predictive of a poor outcome. None of the interventions (volume expansion, catecholamines or steroids) for hypotensive infants improved the outcome Not able to comment which inotropes were beneficial Dopamine Sassano-Higgins et al A meta-analysis of dopamine use in hypotensive preterm infants: Blood pressure and cerebral hemodynamics Preterm infants Meta analysis Dopamine effect on Hypotension CNS injury Dopamine increases mean arterial blood pressure (12 studies; n = 163; r = 0.88, 95%CI: 0.76 to 0.94) and systolic blood pressure (8 studies; n = 142; r = 0.81, 95%CI: 0.42 to 0.94). Dopamine administration was associated with a significantly greater overall efficacy for increase in BP than dobutamine (7 studies; n = 251; r = 0.26; 95%CI: 0.20 to 0.32), colloid (2 studies; n = 67; r = 0.60; 95%CI: 0.41 to 0.74) and hydrocortisone (1 study; n = 28; r = 0.40; 95%CI: 0.034 to 0.67); There were no statistically significant differences in adverse neurological outcomes between dopamine and dobutamine Dopamine is more effective than dobutamine, colloid or hydrocortisone alone.
No increased incidence of adverse effects compared to other therapies Dopamine and dobutamine Subhedar et al Dopamine vs dobutamine for hypotensive preterm infants Preterm infant Cochrane review Effectiveness and safety of dopamine and dobutamine in the treatment of systemic hypotension 5 trials = 209 infants. Fewer infants having treatment failure of hypotension with dopamine than dobutamine (RD -0.23, 95%CI: -0.34 to -0.13; NNT = 4.4, 95%CI: 2.9 to 7.7).
DP: Dose dopamine; EP: Epinephrine; RCT: Randomized clinical trial; LBW: Low birth weight; VLBW: Very low birth weight; TSH: Thyroid stimulating hormone. Dopamine is more effective than dobutamine in increasing BP, but there was no statistical significance in the differences of other outcomes (mortality, periventricular flare, intraventricular haemorrhage grade 3-4, tachycardia). In the articles analysed, doses of dopamine used were not specified, but this drug was administered at a treatment dose for hypotension. This is important as low doses of dopamine (0.5-2 micrograms/kg per minute) act on dopaminergic receptors which usually increases renal perfusion. Medium doses (2-6 micrograms/kg per minute) act on beta-receptors causing vasodilatation and a positive inotropic and chronotropic effect (increasing output and heart rate).
Dopamine For Map
At high doses ( 6-10 micrograms/kg per minute), dopamine acts on alpha-receptors leading mainly to peripheral vasoconstriction. In preterm infants there are differences in receptor maturation depending on the gestation. Hence there is a vasoconstrictive effect in preterms even if dopamine is used at medium doses. On a short term scale, dopamine induces transient and reversible pituitary suppression, however despite this endocrine effect, there is no clinical implication on the infant: Comparing to dobutamine there were no changes with regards to the heart rate, oxygen requirement, fluid intake and mean urine output. However, even though there was significantly decreased, but reversible levels of TSH, T4, and PRL, the long term outcome of this transient suppression remain unknown. In the Cochrane review by Subhedar et al, the effects of dopamine and dobutamine on the left ventricular outflow could not be compared in view of unpublished raw data, yet in a non statistical approach, it seems that dobutamine had more effect on increasing left ventricular outflow.
It is also important to remember the physiological effect of these drugs: Dopamine has a vasoconstrictive effect when acting on the alpha-receptors. Peripheral vasoconstriction by definition will increase systemic BP, but it will also reduce the flow and oxygenation, potentially leading to hypoperfusion in organs such as the brain, the kidneys and the skin. The underlying cause and pathophysiology of decreased BP is essential to take into consideration when treating. Thus it is important to consider different agents in specific situations such as volume deficiency, cardiac failure, sepsis or adrenal insufficiency.
This review was initially aimed at all infants admitted to the neonatal unit, however all evidence points towards the use of inotropes in the preterm infants, therefore the recommendations from this article are aimed at preterm infants with initial hypotension. Therefore, individual treatment for specific conditions was not addressed in this review. Another limitation is that only papers published with high levels of scientific evidence, in the top of the evidence pyramid, have been analysed. Additionally, the literature collected did not focus on direct long-term side effects of the drugs (such as direct effects on brain perfusion and development), independently from their effects on BP.
Other than the above-mentioned inotropes, there are some new drugs such as Milrinone, which is an inotrope/vasodilator and phosphodiesterase inhibitor, and mainly used post cardiac surgery to improve cardiac output. It inhibits an enzyme, which results in an accumulation in cyclic adenosine monophosphate increasing cardiac muscle contractility, and relaxation of the smooth vascular muscle allowing treatment of pulmonary hypertension.
Side effects include arrhythmias. Other drugs like levosimendran and terlipressin, have inotropic effects, but there is not enough evidence in the preterm to promote their usage. The current practice of treating hypotension concentrates on improving the number of the BP, but one may argue it is important to consider the blood flow as well. This idea emerged in 1928 from Jarisch “It is a source of regret that measurement of flow is much more difficult than measurement of pressure. This has led to an undue interest in BP measurements.
Most organs however, require flow rather than pressure”. There are current studies looking at the flow, and the effect in the management of low BP by inotropes: Neocirculation is looking at the effect of dobutamine on the superior vena cava flow, and the TOHOP study looking at NIRS for objective end organ perfusion as an adjunct to management of hypotension. Controversially, other trials are looking at whether hypotension needs to be treated in the initial period of life of a preterm infant; the concept of permissive hypotension is becoming more common. Even though it is known that low BP in a preterm infant is associated with adverse outcomes, it remains unknown whether treatment of hypotension improves the outcome. The on-going HIP trial is aiming to determine whether there is a difference in short and long-term outcome in preterm infants in managing hypotension with volume and dopamine vs a permissive placebo approach.
In this review, we are only able to comment on preterm infants. Term infants usually have multiple aetiologies for hypotension like hypovolaemia, cardiogenic shock, septic shock, endocrine causes like congenital adrenal hyperplasia, sedation drugs, and there have been no studies with high levels of evidence which have compared various inotropes in a term infant. In preterm infants, dopamine is the most studied drug, is more effective in increasing BP than dobutamine. There was no difference in morbidity and mortality outcomes when dopamine was compared to hydrocortisone or adrenaline. In preterm infants, dopamine is effective, and in general safer than others to use. All evidence points towards the fact that dopamine can be considered as a first line inotrope in preterm neonatal hypotension. Conflict-of-interest statement: No potential conflict of interest.
Dopamine Maca
No financial support. Data sharing statement: Statistical code and dataset available from the corresponding author at sadafbhayat@gmail.com. Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: Peer-review started: July 31, 2015 First decision: December 4, 2015 Article in press: January 19, 2016 P- Reviewer: Classen CF, Sangkhathat S, Watanabe T S- Editor: Song XX L- Editor: A E- Editor: Wang CH b.