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SSAI Guideline on choice of inotropic agent in acute circulatory failure :


SSAI Guideline on choice of inotropic agent in acute circulatory failure :

Inotropic agents are defined as drugs with positive inotropic effect leading to increased stroke volume and cardiac output.Adult critically ill patients often suffer from acute circulatory failure and those with low cardiac output may be treated with inotropic agents.The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine SSAI has released its guideline on the choice of inotropic agent in adult patients with acute circulatory failure with an aim to present patient-important treatment recommendations on this topic.The committee members systematically searched PubMed, Cochrane Library, and Epistemonikos for systematic reviews of randomized clinical trials (RCTs) and RCTs comparing dobutamine with other inotropic agents on 25 September 2017.The Guidelines have been published in Acta Anaesthesiologica Scandinavica.

This guideline was developed according to GRADE and following subpopulations of patients with shock were assessed : (1) shock in general, (2) septic shock, (3) cardiogenic shock, (4) hypovolemic shock, (5) shock after cardiac surgery, and (6) other types of shock, including vasodilatory shock. We assessed patient-important outcome measures, including mortality and serious adverse reactions.

Key recommendations –

  • For all patients, routine use of any inotropic agent, including dobutamine is not suggested as inotropic agent for patients with other types of shock including vasodilatory shock compared to placebo/no treatment (very low quality of evidence).
  • For patients with shock in general, and in those with septic and other types of shock, it is suggested that dobutamine should be used rather than levosimendan or epinephrine (very low quality of evidence).
  • For patients with cardiogenic shock and in those with shock after cardiac surgery,  use of dobutamine is suggested rather than milrinone (very low quality of evidence).

For the remaining clinical questions, the expert group refrained from giving any recommendations or suggestions. In general, the quality of evidence was very low, implying high uncertainty on the balance between the benefits and harms when using inotropes in adult patients with acute circulatory failure. Consequently, RCTs with low risk of bias should be a high research priority in settings where inotropes are used.

The results and recommendations based on the PICOs are presented below-

A.Dobutamine vs. other inotropes in patients with shock in general

  • We suggest that dobutamine is used as the inotropic agent for patients with shock in general rather than levosimendan (weak recommendation, very low quality of evidence).
  • Dobutamine vs. milrinone for patients with shock in general: no recommendation/suggestion.
  • We suggest that dobutamine is used as the inotropic agent for patients with shock in general rather than epinephrine (weak recommendation, very low quality of evidence).
  • Dobutamine vs. dopamine for patients with shock in general: no recommendation/suggestion.
  • We suggest against routine use of dobutamine as inotropic agent for patients with shock in general, as compared to placebo/no treatment (weak recommendation, very low quality of evidence).

B.Dobutamine vs. other inotropes in patients with septic shock

  • We suggest that dobutamine is used as the inotropic agent for patients with septic shock rather than levosimendan (weak recommendation, very low quality of evidence).
  • Dobutamine vs. milrinone for patients with septic shock: no recommendation/suggestion.
  • We suggest that dobutamine is used as the inotropic agent for patients with septic shock rather than epinephrine (weak recommendation, very low quality of evidence).
  • Dobutamine vs. dopamine for patients with septic shock: no recommendation/suggestion.
  • We suggest against routine use of dobutamine as inotropic agent for patients with septic shock, as compared to placebo/no treatment (weak recommendation, very low quality of evidence).

C.Dobutamine vs. other inotropes in patients with cardiogenic shock

  • Dobutamine vs. levosimendan for patients with cardiogenic shock: no recommendation/suggestion.
  • We suggest that dobutamine is used as the inotropic agent for patients with cardiogenic shock rather than milrinone (weak recommendation, very low quality of evidence).
  • Dobutamine vs. epinephrine for patients with cardiogenic shock: no recommendation/suggestion.
  • Dobutamine vs. dopamine for patients with cardiogenic shock: no recommendation/suggestion.
  • We suggest against routine use of dobutamine as inotropic agent for patients with cardiogenic shock, as compared to placebo/no treatment (weak recommendation, very low quality of evidence).

D.Dobutamine vs. other inotropes in patients with hypovolemic shock

  • Dobutamine vs. levosimendan for patients with hypovolemic shock: no recommendation/suggestion.
  • Dobutamine vs. milrinone for patients with hypovolemic shock: no recommendation/suggestion.
  • Dobutamine vs. epinephrine for patients with hypovolemic shock: no recommendation/suggestion.
  • Dobutamine vs. dopamine for patients with hypovolemic shock: no recommendation/suggestion.
  • We suggest against routine use of dobutamine as inotropic agent for patients with hypovolemic shock, as compared to placebo/no treatment (weak recommendation, very low quality of evidence).

 E.Dobutamine vs. other inotropes in patients with shock after cardiac surgery

  • Dobutamine vs. levosimendan for patients with shock after cardiac surgery: no recommendation/suggestion.
  • We suggest that dobutamine is used as the inotropic agent for patients with shock after cardiac surgery rather than milrinone (weak recommendation, very low quality of evidence).
  • Dobutamine vs. epinephrine for patients with shock after cardiac surgery: no recommendation/suggestion.
  • Dobutamine vs. dopamine for patients with shock after cardiac surgery: no recommendation/suggestion.
  • We suggest against routine use of dobutamine as inotropic agent for patients with shock after cardiac surgery, as compared to placebo/no treatment (weak recommendation, very low quality of evidence).

F.Dobutamine vs. other inotropes in patients with other types of shock, including vasodilatory shock

  • We suggest that dobutamine is used as inotropic agent for patients with other types of shock including vasodilatory shock rather than levosimendan (weak recommendation, very low quality of evidence).
  • Dobutamine vs. milrinone for patients with other types of shock including vasodilatory shock: no recommendation/suggestion.
  • We suggest that dobutamine is used as inotropic agent for patients with other types of shock including vasodilatory shock rather than epinephrine (weak recommendation, very low quality of evidence).
  • Dobutamine vs. dopamine for patients with other types of shock including vasodilatory shock: no recommendation/suggestion.

For further reference log on to : DOI: 10.1111/aas.13089

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Dr. Kamal Kant Kohli

Dr. Kamal Kant Kohli

A Medical practitioner with a flair for writing medical articles, Dr Kamal Kant Kohli joined Medical Dialogues as an Editor-in-Chief for the Speciality Medical Dialogues. Before Joining Medical Dialogues, he has served as the Hony. Secretary of the Delhi Medical Association as well as the chairman of Anti-Quackery Committee in Delhi and worked with other Medical Councils of India. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751
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