Comparison of Dopamine and Norepinephrine in the Treatment of Shock
NEJM, 2010 · Multicenter randomized double-blind trial (n=1679)
Clinical question
Is norepinephrine or dopamine superior as the first-line vasopressor in undifferentiated shock?
What the trial found
Dopamine caused significantly more arrhythmias overall than norepinephrine. In the prespecified cardiogenic shock subgroup, dopamine was associated with increased 28-day mortality, whereas mortality did not differ in septic or hypovolemic shock.
Current guideline position
Surviving Sepsis Campaign guidelines strongly recommend norepinephrine as the first-line vasopressor in septic shock over dopamine.
Clinical interpretation
Supports norepinephrine over dopamine as the first-line vasopressor in shock, primarily driven by lower arrhythmogenicity and safety in cardiogenic shock.
Cellular dysoxia, DO2/VO2 physiology, the 4 shock phenotypes, dynamic fluid responsiveness (PLR/PPV) vs fluid tolerance (VExUS), and vasoactive pharmacology.
The subset of sepsis with profound circulatory and cellular/metabolic abnormality — clinically identified by a vasopressor requirement to maintain MAP ≥ 65 mmHg plus lactate > 2 mmol/L despite adequate fluid resuscitation.
Primary pump failure, SCAI staging (A–E), PAC hemodynamics (CPO, PAPi), inotrope selection, emergent revascularization, and mechanical circulatory support.