Levophed and sepsis

If you can find this journal editorial: Shock Volume 26(5), November 2006, pp 529-530

it explains fairly well.

I n addition to what is said below, NE does not cause the tachycardia like dopamine; also this article points out that dopamine interferes with the immunologic response by suppresing hormone release.

Look at the action of Norepinephrine. Norepinephrine is a very potent alpha adrenergic receptor stimulant. This in turn causes direct venous and arterial constriction. In forms of vaodilatory shock such as septic shock, the potential benefit of using Norepinephrine can clearly be appreciated.

If you look at the action of Dopamine, you will find that it is both a beta and alpha adrenergic stimulator stimulant. While you do have some alpha effects with dopamine, you will also have beta effects as well. The beta effects will present as tachycardia, possible increased cardiac output and workload, and ventricular irritability. I have used Dopamine in septic shock patients, but the negative consequences of the beta stimulation must be carefully considered.

Dobutamine on the other hand has more beta effect. So, if you are looking for enhanced cardiac activity, dobutamine may be the medication to consider.

I look at it this way. Draw a line and put alpha on the left, and beta on the right. Norepinephrine will be closer to the alpha, Dopmine will be closer to the middle, and Dobutamine will be closer to the beta. This may help you to see what pressor does what.

http://www.medscape.com/viewarticle/497497_2

Here is a great article outlining the different catecholamine pressors and their use.

Like a previous poster already said, with sepsis, the body is vasodilating which is the main issue, so levo, which is primarily alpha will mostly just constrict the vascular system which is what we want.

http://www.postgradmed.com/issues/2002/03_02/fitch2.htm

Here is an article that shows the alpha/beta table.

It also cites a study that showed better results with Levophed:

"Many patients have persistently low blood pressure when receiving dopamine therapy. Evidence suggests that norepinephrine is superior to dopamine in the treatment of hypotension associated with septic shock. Martin and colleagues (14) studied 32 patients with septic shock unresponsive to fluids. They randomly assigned patients to receive a 6-hour infusion of either dopamine or norepinephrine. Fifteen of 16 patients in the norepinephrine group had improved hemodynamics compared with 5 of 16 in the dopamine group. Patients who received norepinephrine had higher urine output and more improvement in lactic acid levels than patients who received dopamine. Several other studies have shown improved splanchnic tissue perfusion with norepinephrine compared with dopamine."

I ready a study the other day that showed that their is no difference between dopamine and levophed when treating the hypotension of septic shock. Will try to remember where I read it and post back here.

Levo is going to constrict and that's what you want. It doesn't have the strong chronotropic properties that dopamine has, therefore you don't increase your rate and subsequently increase your myocardial o2 demand....which could set you up for a whole other slew of issues in addition to the septic shock.