Norepinephrine or dopamine for septic shock: systematic review of randomized clinical trials

Abstract

Background: There is debate as to the vasopressor agent of choice in patients with septic shock. According to current guidelines either dopamine or norepinephrine may be considered as the first-line agent for the management of refractory hypotension of septic shock.

Objective: The aim of this systematic review was to evaluate randomized clinical trials which compared norepinephrine versus dopamine in critically ill patients with septic shock or in a population of critically ill patients with shock predominantly secondary to sepsis.

Data sources: MEDLINE, Embase, Scopus, Cochrane Register of Controlled Trials and citation review of relevant primary and review articles.

Study selection: Randomized clinical trials that compared norepinephrine with dopamine in critically ill adults with sepsis and reported the 28-day or in-hospital mortality.

Data extraction: We abstracted data on study design, study setting, patient population, 28-day mortality or in-hospital mortality, rate of arrhythmias, hospital length of stay, and ICU length of stay.

Data synthesis: Six studies met our inclusion criteria. These studies included a total of 2043 participants, with 995 in the norepinephrine and 1048 in the dopamine groups. There were 479 (48%) deaths in the norepinephrine group and 555 (53%) deaths in the dopamine group. There was statistically significant superiority of norepinephrine over dopamine for the outcome of in-hospital or 28-day mortality: pooled RR: 0.91 (95% CI 0.83 to 0.99; P = .028). We also found a statistically significant decrease in the rate of cardiac arrhythmias in the norepinephine group as compared to the dopamine group: pooled RR: 0.43 (95% CI 0.26 to 0.69; P ≤ .001). A subgroup analysis that pooled studies in which all the randomized patients had septic shock demonstrated that norepinephrine improved in-hospital or 28-day mortality; however, the results were no longer statistically significant.

Conclusions: The analysis of the pooled studies that included a critically ill population with shock predominantly secondary to sepsis showed superiority of norepinephrine over dopamine for in-hospital or 28-day mortality.