Copyright
©The Author(s) 2016.
World J Clin Pediatr. May 8, 2016; 5(2): 212-222
Published online May 8, 2016. doi: 10.5409/wjcp.v5.i2.212
Published online May 8, 2016. doi: 10.5409/wjcp.v5.i2.212
Table 1 Levels of evidence, according to the oxford centre for evidence based medicine
Level of evidence | Type of study |
1a | Systematic review (with homogeneity) of RCTs |
1b | Individual RCT (with narrow confidence interval) |
1c | All or none (when patients died before the treatment became available, and now some survive) |
2a | Systematic review (with homogeneity) of cohort studies |
2b | Individual cohort study (including low quality RCT) |
2c | “Outcomes” research, ecological studies |
3a | SR (with homogeneity) of case-control studies |
3b | Individual case-control study |
4 | Case-series (and poor quality cohort and case-control studies) |
5 | Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles” |
Table 2 Review of evidence
Ref. | Title of study | Study group | Study type (evidence) | Outcome | Key result | Comment |
All inotropes | ||||||
Dempsey et al[29] | 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[13] | 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[16] | 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). No evidence of a significant difference in neonatal mortality between dopamine and dobutamine (RD 0.02, 95%CI: -0.12 to 0.16), incidence of periventricular leukomalacia (RD -0.08, 95%CI: -0.19 to 0.04), or severe periventricular haemorrhage (RD -0.02, 95%CI: -0.13 to 0.09), or incidence of tachycardia (RD -0.06, 95%CI: -0.25 to 0.14) | Dopamine is more effective than dobutamine in the short term treatment, none of the studies reported the incidence of adverse long term neurodevelopmental outcomes |
Filippi et al[19] | Dopamine vs dobutamine in very low birthweight infants: Endocrine effects | VLBW | Prospective RCT (non-blinded) | Endocrine effects of dopamine and dobutamine in hypotensive VLBW | Suppression of TSH, T(4) and PRL was observed in dopamine-treated newborns from 12 h of treatment onwards, whereas levels of growth hormone reduced significantly only at 12 h and 36 h of treatment (P < 0.01). TSH, T(4) and PRL rebound was observed from the first day onwards after stopping dopamine. Dobutamine administration did not alter the profile of any of the hormones and no rebound was observed after stopping treatment | Dopamine induced a transient pituitary suppression, comparing to dobutamine. But this is totally reversible |
Dopamine and adrenaline | ||||||
Pellicer et al[25] | Cardiovascular support for low birth weight infants and cerebral hemodynamics: A randomized, blinded, clinical trial | LBW | RCT double blinded | Quantitative changes in cerebral concentrations of oxyhemoglobin and deoxyhemoglobin, cerebral intravascular oxygenation (HbD), and cerebral blood volume | Among hypotensive LBW infants, cardiovascular support with low/moderate-DP or low-dose EP increased cerebral perfusion. Low-dose EP was as effective as low/moderate-dose DP in increasing MBP among LBW infants. Heart rate was higher in the EP group than in the DP group (respectively 167 vs 159 when optimal BP was obtained) | Low-dose EP was as effective as low/moderate-dose DP in increasing MBP among LBW infants. EP led to a higher heart rate than DP |
Valverde et al[23] | Dopamine vs epinephrine for cardiovascular support in low birth weight infants: Analysis of systemic effects and neonatal clinical outcomes | LBW | RCT | Short-term changes in heart rate, mean BP, acid-base status, lactate, glycemia, urine output, and fluid-carbohydrate Debit. Medium-term morbidity, enteral nutrition tolerance, gastrointestinal complications, severity of lung disease, patent ductus arteriosus, cerebral ultrasound diagnoses, retinopathy of prematurity, and mortality | Mean blood pressure showed a significant increase from baseline throughout the first 96 h with no differences between groups (dopamine: 36%; epinephrine: 37%). However, epinephrine produced a greater increase in heart rate than dopamine. After treatment began, epinephrine patients showed higher plasma lactate (first 36 h) and lower bicarbonate and base excess (first 6 h) and received more bicarbonate, and had higher blood glucose levels (P < 0.05). For medium-term morbidity, there were no differences in neonatal clinical outcomes in responders | Transitory adverse effects of epinephrine on carbohydrate and lactate metabolism could undermine the use of epinephrine as a first-line inotrope in preterm infants who are prone to such metabolic disturbances |
Paradisis et al[24] (2004, reviewed in 2009) | Adrenaline for prevention of morbidity and mortality in preterm infants with cardiovascular compromise | Preterm infant | Cochrane review | Effectiveness and safety of adrenaline compared to no treatment or other inotropes in reducing mortality and morbidity in preterm infants with cardiovascular compromise | One trial comparing adrenaline with dopamine infusion was included. It enrolled hypotensive, predominantly preterm infants in the first 24 h. Only infants > 1750 g are included in this review. Both adrenaline and dopamine significantly increased heart rate and mean BP, with no statistically significant effect on left or right ventricular outputs. No significant difference was reported between the 2 inotropes | The study was reported as being randomised and double blinded, but methods were not reported. Published abstract, side effects and safety were not reported |
Dopamine and steroids | ||||||
Ibrahim et al[27] | Corticosteroids for treating hypotension in preterm infants | Preterm infant | Cochrane review | Effectiveness and safety of corticosteroids used either as primary treatment of hypotension or for the treatment of refractory hypotension | 4 studies were included in this review enrolling a total of 123 babies. In one study, persistent hypotension was more common in hydrocortisone treated infants as compared to those who received dopamine as primary treatment for hypotension (RR 8.2, 95%CI: 0.47 to 142.6; RD 0.19, 95%CI: 0.01 to 0.37). There were no statistically significant effects on any other short or long-term outcome | Long term benefit or safety data is lacking with steroids |
- Citation: Bhayat SI, Gowda HMS, Eisenhut M. Should dopamine be the first line inotrope in the treatment of neonatal hypotension? Review of the evidence. World J Clin Pediatr 2016; 5(2): 212-222
- URL: https://www.wjgnet.com/2219-2808/full/v5/i2/212.htm
- DOI: https://dx.doi.org/10.5409/wjcp.v5.i2.212