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Uses

Cardiac Decompensation, Shock, and CHF

Used to increase cardiac output in the short-term treatment of cardiac decompensation caused by depressed contractility from organic heart disease, cardiac surgical procedures, cardiac arrest† (ACLS; see CPR under Uses), or acute MI† (see MI under Uses).

May be particularly useful in the management of cardiogenic shock in normal DBP and SBP >100 mm Hg, since the drug provides the best sympathomimetic support.

May be preferable to dopamine in the period immediately following cardiopulmonary bypass surgery for use in low cardiac output syndrome following open heart surgery can increase long-term survival.

Safety and efficacy in the long-term (e.g., exceeding 48 hours) treatment of CHF have not been established. Patients with NYHA class IV disease appear at particular risk of adverse effects of long-term cAMP-dependent inotropic therapy.

May be ineffective and potentially harmful in marked mechanical obstruction (e.g., severe valvular aortic stenosis).

Should not be used alone in severely hypotensive patients (e.g., when SBP is <100 mm Hg).

CPR

Used as a potent inotropic agent to increase cardiac output in ACLS during CPR.

May be particularly useful for low cardiac output secondary to poor myocardial function, such as following cardiac arrest.

Predominant β-adrenergic effects that increase myocardial contractility in a dose-dependent manner and decrease left ventricular filling pressures.

Arterial blood pressure may remain unchanged due to reflex peripheral vasodilation (baroreceptor mediated) in response to increased stroke volume.

Useful in the management of postresuscitation shock (e.g., when combined with dobutamine).

MI

Although the manufacturers state that safety following MI has not been established , use in combination with dopamine in acute MI† management is recommended by the ACC and AHA for the management of heart failure and low-output syndromes associated with left ventricular dysfunction and for inotropic support following hypotension management associated with right ventricular ischemia.

May be useful as an adjunct (to increase cardiac output) to volume replacement in patients with right ventricular infarction, since dopamine may increase pulmonary vascular resistance.

Dosage and Administration

General

Administration

Usually administered by IV infusion

Has also been administered by intraosseous infusion†.

IV Infusion

Infuse IV using an infusion pump or other apparatus to control the rate of flow and avoid inadvertent administration of a bolus of drug.

Commercially available premixed dobutamine hydrochloride in 5% dextrose should be administered only by IV infusion via a suitable catheter or needle.

Do not be use in series connections.

When the commercially available IV infusion solution of dobutamine hydrochloride in 5% dextrose is used, the accompanying labeling should be consulted for proper methods of administration and other associated precautions.

Dilution

The concentrate for injection must be diluted prior to administration; alternatively, commercially available diluted injections for IV infusion may be used.

20 mL of the concentrate for injection should be diluted in at least 50 mL of diluent and 40 mL of concentrate should be diluted in at least 100 mL of diluent.

The concentration used is individualized according to patient dosage and fluid requirements, but should not exceed 5000 mcg (5 mg)/mL.

Rate of Administration

Avoid bolus administration.

Rate of IV infusion varies according to individual dose requirements titrated to response, but usually ranges from 2–20 mcg/kg per minute.

Intraosseous Administration

When IV administration is not possible, dobutamine may be given by intraosseous administration for emergency uses such as CPR.

Limit intraosseous administration to personnel well trained in the technique.

Place a cannula in a noncollapsible marrow venous plexus; such access often can be achieved in 30–60 seconds. Use a rigid needle, preferably a specially designed intraosseous or Jamshidi-type bone marrow needle; a styleted needle is preferred to prevent obstruction of the needle with cortical bone.

Insert the intraosseous needle into the anterior tibial bone marrow; alternatively, the distal femur, medial malleolus, or anterior superior iliac spine can be used. In older children and adults, intraosseous cannulas also have been inserted successfully into the distal radius or ulna in addition to the proximal tibia.

Successful placement outside the hospital (e.g., by emergency medical services) generally is more difficult in older than in younger children.

Onset of action and systemic concentrations are comparable to those achieved with intravascular administration.

Dilution

Same as those for IV infusion. (See Dilution under IV Infusion.)

Rate of Administration

Intraosseous infusion rates are the same as those for IV infusion. (See Rate of Administration under IV Infusion.)

Administration Risks

Complications are uncommon (less than 1% of patients), and include tibial fracture, lower-extremity compartment syndrome, extravasation, and osteomyelitis; careful technique can minimize the risk. Local effects on bone marrow and bone growth appear to be minimal. Risk of microscopic pulmonary fat and bone marrow emboli does not appear to be increased.

Dosage

Available as dobutamine hydrochloride; dosage expressed in terms of dobutamine.

Hemodynamic end points rather than a specific dose should be employed to optimize therapy.

Individual response to dobutamine is variable, and infusion rate should be titrated to achieve the desired clinical response.

Rate and duration of should be carefully adjusted according to patient response as indicated by heart rate, BP, urine flow, peripheral perfusion, presence of ectopic heartbeats, and, whenever possible, by measurement of central venous or pulmonary wedge pressure and cardiac output.

Usually initiate slowly (e.g., 0.5–1 mcg/kg per minute).

Pediatric Patients

Pharmacokinetics and clinical responses to specific doses vary widely.

Hemodynamic end points rather than a specific dose should be employed to optimize therapy with the drug.

Cardiac Decompensation and Shock

IV or Intraosseous

Usually, 2–20 mcg/kg per minute is needed to increase cardiac output.†

CPR

IV or Intraosseous

Usually, 2–20 mcg/kg per minute is needed to increase cardiac output.†

MI

IV or Intraosseous

Usually, 2–20 mcg/kg per minute is needed to increase cardiac output.†

Adults

Individual response to dobutamine is variable, and infusion rate should be titrated to achieve the desired clinical response.

Hemodynamic end points rather than a specific dose should be employed to optimize therapy with the drug.

Initiate at a slow rate (e.g., 0.5–1 mcg/kg per minute) and carefully adjust at intervals of a few minutes according to response.

Dobutamine has been infused for up to 72 hours without decreased effectiveness.

Cardiac Decompensation and Cardiopulmonary Resuscitation

IV or Intraosseous

Usually, 5–20 mcg/kg per minute, but inotropic and chronotropic responses vary widely.†

CPR

IV or Intraosseous

Usually, 5–20 mcg/kg per minute, but inotropic and chronotropic responses vary widely.†

MI

IV or Intraosseous

Usually, 5–20 mcg/kg per minute, but inotropic and chronotropic responses vary widely.†

Prescribing Limits

Pediatric Patients

IV or Intraosseous

Dosages >20 mcg/kg per minute may produce tachycardia and ventricular ectopy and could induce or exacerbate myocardial ischemia.†

Adults

IV or Intraosseous

Dosages >20 mcg/kg per minute often increase heart rate by more than 10%, and such increases potentially could induce or exacerbate myocardial ischemia.†

Rarely, dosages as great as 40 mcg/kg per minute, but these often are toxic and usually should be avoided.†

Special Populations

Dosage in Hepatic Impairment

No specific hepatic dosage recommendations.

Dosage in Renal Impairment

No specific renal dosage recommendations.

Geriatric Patients

Geriatric patients may exhibit a substantially decreased response.