A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip

The FDA approveD dobutamine for short-term use in patients with decreased contractility due to heart failure or cardiac surgical procedures leading to cardiac decompensation. The agent has not been shown to give positive outcomes in the hospitalized or outpatient setting for heart failure patients despite hemodynamically improving the patient's condition. Dobutamine can be used as temporary intravenous inotropic support until resolution of the acute inducing factors or the patient receives more definitive treatment, such as coronary revascularization, mechanical circulatory support, or heart transplant. Short-term intravenous inotropic support should be given to patients in cardiogenic shock to preserve systemic blood flow and protect from end-organ damage. This activity will highlight the mechanism of action, adverse event profile, pharmacology, monitoring, and relevant interactions of dobutamine, pertinent for members of the interprofessional team in treating patients with cardiac disorders that will respond to such therapy.

Objectives:

• Identify the various indications for dobutamine.

• Outline the adverse event profile for dobutamine.

• Review the mechanism of action of dobutamine that leads to its therapeutic effects.

• Summarize interprofessional team strategies for improving care coordination and communication to advance diabetes management and improve outcomes by using dobutamine.

In 1975, pharmacologist Tuttle and chemist Mills, discover the compound dobutamine by modifying the structure of isoproterenol/isoprenaline. They published an article "Dobutamine: development of a new catecholamine to selectively increase cardiac contractility"[1]

Dobutamine is approved by the Food and Drug Administration (FDA) for short-term use in patients with decreased contractility due to heart failure or cardiac surgical procedures leading to cardiac decompensation.[2] The agent has not demonstrated positive outcomes in the hospital or outpatient setting for heart failure patients despite hemodynamically improving the patient’s condition.

Dobutamine can be used as temporary intravenous inotropic support until resolution of the acute inducing factors or the patient receives more definitive treatment, such as coronary revascularization, mechanical circulatory support, or heart transplant. Short-term intravenous inotropic support should be given to patients in cardiogenic shock to preserve systemic blood flow and protect from end-organ damage.

Patients can reasonably receive dobutamine in continuous intravenous form for inotropic support to bridge patients with late-stage heart failure, stage D, that is refractory to guideline-directed medical therapy until patients who are candidates for and awaiting cardiac transplantation or mechanical circulatory support receive the appropriate long-term treatment.[3]

Continuous intravenous inotropic dobutamine support can reasonably be given in the short term for hospitalized patients with severe systolic dysfunction who present with low blood pressure and a significantly decreased cardiac output to preserve systemic blood flow and protect from end-organ damage.

Continuous intravenous inotropic dobutamine support can reasonably be given for the long-term in palliative patients with late-stage heart failure, stage D, who are not candidates for mechanical circulatory support or cardiac transplantation for symptomatic control, regardless of guideline-directed medical therapy.[4]

Intravenous inotropic dobutamine can be given off-label to patients to induce pharmacological stress during stress echocardiography if patients cannot perform an exercise stress test.[5][6]

Dobutamine is used as a pharmacological agent and has both ionotropic and chronotropic effects depending on the dose. Because of its inotropic effects on the myocardium through binding and activating the beta-1 receptors selectively.[7] The medication is indicated clinically for decompensated congestive heart failure because of the sympathomimetic effects. Dobutamine's ionotropic effect increases contractility, leading to decreased end-systolic volume and, therefore, increased stroke volume. The increase in stroke volume leads to an augmentation of the cardiac output of the heart.[8] The changes in cardiac output allow for the baroreceptor-mediated response to decrease the systemic vascular resistance and cause little to no change in the arterial blood pressure. In addition to the well-known beta-1 activity, dobutamine has been shown to have some beta-2 activity, which contributes to the reduction in the systemic vascular resistance, and alpha-1 activity, to an even lesser extent, whose vasoconstrictive effects are negated by the baroreceptor mediated response and beta-2 activity.

Dobutamine administration is via large intravenous access and infusion pump for inotropic support in decompensated congestive heart failure, stress echocardiogram, and stress nuclear testing. The dosage for cardiac decompensation in heart failure can begin with one-half to one mcg/kg/min and increase up to a maximum of 40 mcg/kg/min. The lower doses of dobutamine can be prescribed at 2.5 to 5.0 mcg/kg/min, and the higher end of dobutamine doses can be 5.0 to 20.0 mcg/kg/min.[9] The dose for the stress echocardiogram and stress nuclear test is initiated at five mcg/kg/min and can be increased in intervals of 10 mcg/kg/min every 3 to 5 minutes until reaching the target heart rate. Dobutamine comes in a solution as a racemic mixture of both positive and negative enantiomers for intravenous administration. The positive enantiomer in the solution is predominately selective for the beta sympathetic receptors, mainly beta 1 and 2, whereas the negative enantiomer has been shown in studies to be selective for the alpha one receptors.[10]

Dobutamine administration can lead to possible adverse reactions, mainly due to sympathomimetic activity. The majority of patients taking this medication have experienced a rise in the systolic blood pressure of 10 to 20 mmHg and an increase of 5 to 10 beats per minute in their heart rate. There have been reports of further increases in systolic blood pressure and heart rate. In about 10% of the patients, there can be a rise of 30 beats per minute or more in the heart rate, and in about 7.5% of patients, there can be an increase of 50 mmHg or more in the systolic blood pressure. Patients with preexisting hypertension are more susceptible to the adverse effects on systolic blood pressure when using dobutamine.[11]

Dobutamine increases the risk of rapid ventricular response in patients with preexisting atrial fibrillation. The recommendation is that these patients use a regimen of digoxin before starting dobutamine to decrease the risk of developing atrial fibrillation with a rapid ventricular response. There has been an increased risk of developing premature ventricular beats during the administration of dobutamine. About 5% of patients experience premature ventricular beats.[12]

Other adverse effects caused by this medication include hypotension rarely. While increases in systolic blood pressure are common due to dobutamine, hypotension can occur less frequently due to the decreases in systemic vascular resistance. Recommendations include decreasing the dose or stopping the drug to reverse the hypotensive effects.

Phlebitis at the site of the intravenous administration can occur, but it an uncommon reaction. Dobutamine can rarely reduce the potassium concentrations to hypokalemic levels. Other rare adverse effects have occurred in one to three percent of the patients, including nausea, headaches, chest pain, palpitations, and shortness of breath. Dobutamine contains sulfite, which can lead to reactions in rare patients with sulfite hypersensitivity.

According to the Food and Drug Administration, Dobutamine use is contraindicated in patients with a noted history of allergic reactions to either previous dobutamine use or any sulfite use. The medication is contraindicated in patients with acute myocardial infarction, unstable angina, left main stem disease, severe hypertension, arrhythmias, acute myocarditis or pericarditis, hypokalemia and idiopathic hypertrophic sub-aortic stenosis.

Throughout the administration of this medication, there should be continuous monitoring using cardiac monitor and blood pressure checks because dobutamine is typically given to unstable patients and can lead to serious effects quickly that require monitoring and corrective action. The clinician can reduce the dose of dobutamine or stop the medication if the patient experiences adverse effects.

Dobutamine toxicity is rare, and the half-life is short at 2 minutes. Symptoms are generally due to sympathetic overstimulation and can include chest pain, palpitations, headaches, tremors, shortness of breath, nausea, and vomiting. To reverse the tachycardia caused by dobutamine, metoprolol intravenous can be given.

Dobutamine is a medication used in the ICU to manage low blood pressure. While the drug is safe, its use requires close monitoring as it has the potential to raise blood pressure and cause arrhythmia. Therefore the involvement of an interprofessional healthcare team is the optimal approach to ensuring therapeutic effectiveness and avoiding adverse effects. This team includes clinicians, specialists, mid-level practitioners, nurses, and pharmacists. Nurses perform IV dobutamine administration; hence these professionals should be familiar with the dosing and what parameters to monitor. Overall, the effects of dobutamine are short-lived. As soon as the infusion stops, the hemodynamic parameters will reverse. Collaboration and open communication between all interprofessional team members will drive the best patient results with dobutamine and any other drugs or procedures. [Level 5]

Review Questions

Dobutamine Pressure Volume Loop. Contributed by StatPearls

1.

Tuttle RR, Mills J. Dobutamine: development of a new catecholamine to selectively increase cardiac contractility. Circ Res. 1975 Jan;36(1):185-96. [PubMed: 234805]

McNally EM. Can we do better than dobutamine? Circ Res. 2013 Aug 02;113(4):355-7. [PMC free article: PMC3869564] [PubMed: 23908327]

Stevenson LW. Clinical use of inotropic therapy for heart failure: looking backward or forward? Part I: inotropic infusions during hospitalization. Circulation. 2003 Jul 22;108(3):367-72. [PubMed: 12876135]

Martens P, Vercammen J, Ceyssens W, Jacobs L, Luwel E, Van Aerde H, Potargent P, Renaers M, Dupont M, Mullens W. Effects of intravenous home dobutamine in palliative end-stage heart failure on quality of life, heart failure hospitalization, and cost expenditure. ESC Heart Fail. 2018 Aug;5(4):562-569. [PMC free article: PMC6073033] [PubMed: 29341466]

Currie GM. Pharmacology, Part 4: Nuclear Cardiology. J Nucl Med Technol. 2019 Jun;47(2):97-110. [PubMed: 30770476]

Lattanzi F, Picano E, Adamo E, Varga A. Dobutamine stress echocardiography: safety in diagnosing coronary artery disease. Drug Saf. 2000 Apr;22(4):251-62. [PubMed: 10789822]

Alhayek S, Preuss CV. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 11, 2021. Beta 1 Receptors. [PubMed: 30422499]

Kislitsina ON, Rich JD, Wilcox JE, Pham DT, Churyla A, Vorovich EB, Ghafourian K, Yancy CW. Shock - Classification and Pathophysiological Principles of Therapeutics. Curr Cardiol Rev. 2019;15(2):102-113. [PMC free article: PMC6520577] [PubMed: 30543176]

Erlemeier HH, Kupper W, Bleifeld W. Intermittent infusion of dobutamine in the therapy of severe congestive heart failure--long-term effects and lack of tolerance. Cardiovasc Drugs Ther. 1992 Aug;6(4):391-8. [PubMed: 1520649]

Ruffolo RR. The pharmacology of dobutamine. Am J Med Sci. 1987 Oct;294(4):244-8. [PubMed: 3310640]

Mertes H, Sawada SG, Ryan T, Segar DS, Kovacs R, Foltz J, Feigenbaum H. Symptoms, adverse effects, and complications associated with dobutamine stress echocardiography. Experience in 1118 patients. Circulation. 1993 Jul;88(1):15-9. [PubMed: 8319327]

David S, Zaks JM. Arrhythmias associated with intermittent outpatient dobutamine infusion. Angiology. 1986 Feb;37(2):86-91. [PubMed: 3954157]