An appraisal of selection and use of catecholamines in septic shock - old becomes new again
ABSTRACT
The use of catecholamines to defend and resuscitatepatients with septic shock remains a cornerstone ofintensive care medicine. The pharmacological support ofthe failing circulation during sepsis and septic shock shouldbe directed at augmenting perfusion of vital organs andfacilitating venous return, rather than peripheral arterialvasoconstriction. There appears to be a teleologicalrationale for primary use of catecholamines to augmentfailing endogenous neurohumoral and neuroendocrinecardiovascular systems. To this end, it seems intuitive to usethe predominant naturally occurring catecholamine,noradrenaline, as the first-line agent for circulatory failure,although there are no definitive clinical trials to support this.Adrenaline has an established place in many parts of theworld, particularly low-income countries, and appears to beequivalent to noradrenaline for reversing septic shock.There is increasing evidence for adverse neuroendocrineand immunological effects of dopamine, warrantingcircumspection about its use. The use of synthetic inotropesand vasopressors for septic shock remains limited, with littlebiological rationale. Clinicians should wait for definitiveoutcome-based trials of these expensive agents beforeincorporating them into practice. Supplemental endocrinereplacement therapy with low-dose corticosteroids andvasopressin appears biologically plausible and has anemerging role.
Results of large-scale, high-quality trials of endogenouscatecholamines for sepsis and septic shock are awaited.These may provide additional, important information forevidence-based guidelines, which currently remain oflimited clinical utility.
Crit Care Resusc 2006; 8: 353-360
