Dopamine versus dobutamine for hypotensive preterm infants

  • Review
  • Intervention

Authors


Abstract

Background

Inotropes are widely used in preterm infants to treat systemic hypotension. The most commonly used drugs are dopamine and dobutamine. These agents have different modes of action which may result in different haemodynamic effects.

Objectives

To compare the effectiveness and safety of dopamine and dobutamine in the treatment of systemic hypotension in preterm infants.

Search methods

Searches of electronic and other databases were performed including MEDLINE (1966-2002), EMBASE (1988-2002), Science Citation Index (1981-2002), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2003). Previous reviews were searched for references to relevant trials and leading authors in the field were contacted for information about other published and unpublished studies.

Selection criteria

Randomised controlled trials where short and/or long term effects of treatment with dopamine and dobutamine for the treatment of systemic arterial hypotension were compared were selected for this review. Trials studying newborn infants born before 37 completed weeks gestation and less than 28 days of age were eligible for inclusion. Systemic arterial hypotension was not defined specifically, but accepted as defined in individual studies. Studies were not limited by birthweight, lower gestational age threshold or by route or duration of administration of inotropic agents. Study quality and eligibility were assessed independently by each reviewer.

Data collection and analysis

Data extraction was performed independently by each reviewer, with differences being resolved by discussion. The following outcomes were determined: mortality in the neonatal period, long term neurodevelopmental outcome, radiological evidence of severe neurological injury, short term haemodynamic changes and incidence of adverse effects. The effect of interventions was expressed either as Relative Risk (RR), Risk Difference (RD) or as Weighted Mean Difference (WMD) with their 95% Confidence Interval (CI).

Main results

Five trials met the pre-defined criteria for inclusion in this review. There was no evidence of a significant difference between dopamine and dobutamine in terms of neonatal mortality (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). Dopamine was more successful than dobutamine in treating systemic hypotension, with fewer infants having treatment failure (RD -0.23, 95% CI -0.34 to -0.13; NNT = 4.4, 95% CI 2.9 to 7.7). Treatment with dobutamine was associated with a significantly greater increase in left ventricular output in the single study reporting that outcome. There was no evidence of a significant difference between the two agents with respect to the incidence of tachycardia (RD -0.06, 95% CI -0.25 to 0.14). None of the studies reported the incidence of adverse long term neurodevelopmental outcome.

Authors' conclusions

Dopamine is more effective than dobutamine in the short term treatment of systemic hypotension in preterm infants. There was no evidence of an effect on the incidence of adverse neuroradiological sequelae (severe periventricular haemorrhage and/or periventricular leucomalacia), or on the incidence of tachycardia. However, in the absence of data confirming long term benefit and safety of dopamine compared to dobutamine, no firm recommendations can be made regarding the choice of drug to treat hypotension.

摘要

背景

巴胺(dopamine)和多巴酚丁胺(dobutamine)對於早產兒低血壓的應用比較

強心劑被廣泛應用於治療早產兒的全身性低血壓。最常用的藥物是多巴胺和多巴酚丁胺。這些藥劑因有不同的作用模式而導致不同的血流動力學的影響。

目標

比較使用多巴胺和多巴酚丁胺在治療早產兒全身性低血壓的效力及安全性。

搜尋策略

經由電子資料庫所搜尋的數據包括MEDLINE(1966 – 2002) ,EMBASE(1988 – 2002),Science Citation Index(1981 – 2002),the Cochrane Central Register of Controlled Trials(CENTRAL, Cochrane Library,Issue 2,2003)。回顧早先的相關研究數據並與在專業領域中的主要作者取得聯繫以取得其已發表及未發表的研究數據。

選擇標準

隨機取樣已使用多巴胺和多巴酚丁胺在短期或長期治療全身動脈性低血壓的案例來做為互相比較的依據。案例納入研究的條件為懷孕週數滿37週和出生少於28天的新生兒。全身動脈性低血壓是沒有明確定義但可接受被定義在單獨研究中。此研究不受出生體重、較低孕齡門檻、使用強心劑的途徑或時間的限制。研究的品質和資格將由檢閱者進行獨立的評估。

資料收集與分析

數據取樣是由各個作者獨立的執行並一同討論其中的差異性。產生了決定性的結果,包括持續追蹤:新生兒期的死亡率、神經發展的長期性影響的發生率,神經嚴重損傷後的影像證據,短期血流動力學的改變及副作用的發生率。這些不良影響以相對危險(RR),風險差異(RD),或weighted mean difference(WMD)、95%信賴區間(CI)來顯示。

主要結論

回顧檢討中包括了五個符合預定標準的試驗。目前還沒有任何證據顯示多巴胺和多巴酚丁胺兩者在治療新生兒死亡率中有顯著性差異(RD 0.02;95% CI為−0.12 to 0.16),以及腦室周圍白質軟化症罹病率(RD −0.08; 95% CI為−0.19 to 0.04),或嚴重的週邊血管出血(RD −0.02,95% CI0.13 to 0.09)。多巴胺比多巴酚丁胺在治療全身性低血壓的成效較好,較少的嬰幼兒有治療失敗的結果(RD −0.23,95% CI −0.34 to −0.13; NNT = 4.4, 95% CI為2.9 to 7.7)。在一個研究發表結果顯示使用多巴酚丁胺治療可以促進左心室輸出量顯著的增加。對於心搏過速的影響目前還沒有證據顯示兩者間有任何顯著性差異(RD −0.06,95% CI −0.25 to 0.14)。沒有研究報告顯示會不利於長期腦神經的發展。

作者結論

在短期內治療系統性低血壓的早產兒,多巴胺是比多巴酚丁胺更有效。目前還沒有任何證據證實會發生神經放射學的不良後遺症(嚴重的周邊血管出血和或腦室周圍白質軟化症)或發生心搏過速。然而,在缺乏數據確認多巴胺和多巴酚丁胺相較下的長遠利益和安全性,仍無法強烈的建議選擇這方面藥物來治療低血壓。

翻譯人

本摘要由臺中榮民總醫院王瑩翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

多巴胺比多巴酚丁胺在短期內改善早產兒血壓低(低血壓)更有效,但需要的是安全性和長期有效性的證據。早產兒(37週前出生的)發生低血壓可能會導致腦損傷和其他嚴重的問題。治療目標是保持到腦部和其他器官的血流,用輸液或藥物,以提升血壓。包括多巴胺和多巴酚丁胺的強心劑是普遍用來提升血壓的。然而,最安全及最有效治療早產兒低血壓的藥物一直不明確。本回顧發現,多巴胺比多巴酚丁胺在短期治療是更有效,但這些藥物長期的效果是未知的。因此我們需要更多的驗證。

Plain language summary

Dopamine versus dobutamine for hypotensive preterm infants

Dopamine improves low blood pressure (hypotension) in preterm babies more effectively than dobutamine in the short-term, but evidence on safety and long-term effectiveness is needed. Hypotension may cause brain injury and other serious problems for preterm babies (born before 37 weeks). Treatment aims to maintain blood flow to the brain and other organs, by using fluids or drugs to increase blood pressure. Inotrope drugs, including dopamine and dobutamine, are commonly used to increase blood pressure. However, the safest and most effective drug for treating hypotension in preterm babies has been unclear. The review found that dopamine was more effective than dobutamine for short-term treatment, but the effects of these drugs on long-term outcomes is unknown. More trials are needed.

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