Na Vs Dp

new england journal of medicine
The
established in 1812

march 4, 2010

vol. 362

no. 9

Comparison of Dopamine and Norepinephrine in the Treatment of Shock
Daniel De Backer, M.D., Ph.D., Patrick Biston, M.D., Jacques Devriendt, M.D., Christian Madl, M.D., Didier Chochrad, M.D., Cesar Aldecoa, M.D., Alexandre Brasseur, M.D., Pierre Defrance, M.D., Philippe Gottignies, M.D., andJean-Louis Vincent, M.D., Ph.D., for the SOAP II Investigators*

A BS T R AC T
BACKGROUND

Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other.
METHODS

In this multicenter, randomized trial, we assigned patients with shock to receive either dopamine ornorepinephrine as first-line vasopressor therapy to restore and maintain blood pressure. When blood pressure could not be maintained with a dose of 20 μg per kilogram of body weight per minute for dopamine or a dose of 0.19 μg per kilogram per minute for norepinephrine, open-label norepinephrine, epinephrine, or vasopressin could be added. The primary outcome was the rate of death at 28 days afterrandomization; secondary end points included the number of days without need for organ support and the occurrence of adverse events.
RESULTS

The trial included 1679 patients, of whom 858 were assigned to dopamine and 821 to norepinephrine. The baseline characteristics of the groups were similar. There was no significant between-group difference in the rate of death at 28 days (52.5% in thedopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P = 0.10). However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P12 mm Hg or in pulmonaryartery occlusion pressure to >14 mm Hg) and if there were signs of tissuehypoperfusion (e.g., altered mental state, mottled skin, urine output of 2 mmol per liter). Patients were excluded if they were younger than 18 years of age; had already received a vasopressor agent (dopamine, norepinephrine, epinephrine, or phenylephrine) for more than 4 hours during the current episode of shock; had a serious arrhythmia, such as rapid atrial fibrillation (>160 beats per minute)or ventricular tachycardia; or had been declared brain-dead.
Protocol

Randomization was performed in computer-generated, permuted blocks of 6 to 10, stratified according to the participating ICU. Treatment assignments and a five-digit reference number were placed in sealed, opaque envelopes, which were opened by the person responsible for the preparation of the trial-drug solutions. Thesolutions of norepinephrine or dopamine were prepared in vials or syringes according to the preference of the local ICU. Each vial or syringe was then labeled with its randomly allocated number. The doctors and nurses administering the drugs, as well as the local investigators and research personnel who collected data, were unaware of the treatment assignments. The trial was approved by the ethicscommittee at each participating center. Written informed consent was obtained from all patients or next of kin.
march 4, 2010

n engl j med 362;9

nejm.org

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Dopamine and norepinephrine in shock

The dose was determined according to the patient’s body weight. Doses ofdopamine could be increased or decreased by 2 μg per kilogram per minute and doses of norepinephrine by 0.02 μg per kilogram per minute (or more in emergency cases) (see Fig. 1 and 2 in the Supplementary Appendix, available with the full text of this article at NEJM.org). An example of the dose-escalation table is provided in Table 1 in the Supplementary Appendix. The target blood pressure was...