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Three Part Question

In [critically ill non elective surgery adults] is [dopexamine] an [effective means to prevent renal failure]

Clinical Scenario

A 62 year old, has been admitted to the intensive care unit following an emergency Hartmann’s procedure for a perforated diverticulum. He is clearly septic, with persistent pyrexia, hypotension, tachycardia and is being ventilated. He has been started on the sepsis bundle, including noradrenaline to maintain a decent MAP. He has a past medical history of treated hypertension, hypercholesterolaemia, and diverticullar disease.

It is clear that low dose dopamine has no renal protective effects but, you discuss the use of dopexamine on the ward round as an alternative. No one clear about the evidence for and against so you investigate.

Search Strategy

Medline 1966-current
[Dopexamine.af] and [Renal failure.af] and [critical care.af] or [intensive care.af]
Limited to human and English language

Search Outcome

54 papers were found using the above search criteria, after exclusion of papers that were not relevant, 10 abstracts were reviewed three of which are presented in table 1.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Takala et al 2000 Six European countries	433 patients defined as being high risk were randomised to placebo (144), 0.5µg/kg/min (143), 2.0µ/kg/min (145) Treatment was started after stabilisation with fluids, blood products and oxygen as appropriate	Prospective randomised control double blind multi-centre trial	Post-operative mortality and morbidity	No Benefit	A high proportion of patients in the study were high risk only because they were having planned extensive, ablative surgery for carcinoma or prolonged surgery >8hrs. This accounts for 78.3%
			Renal dysfunction	No Benefit
Ralph et al 2002 UK	102 critically ill patients in two adult intensive care units. 52-treatment group 50-control Dopexamine started at 0.5µg/kg/min and increased every 30mins Treatment started after resuscitation	Prospective randomised control trial	Creatinine clearance	No Benefit	Method used to randomise patient not discussed
			Organ dysfunction	No Benefit
			Gastrointestinal absorption	No Benefit
Schmoelz et al 2006 Germany	61 with defined septic shock over a 3-year period were identified 20-dopexamine group 20-placebo group 21-dopamine group 2µg/kg/min-dopexamine 3µg/kg/min-dopamine	A prospective, randomized, controlled, double-blinded study	Renal function parameters	No Benefit	A major limitation is the small sample size
			Organ failure scores	No Benefit

Comment(s)

All the studies showed no beneficial effects on the preservation of renal function with dopexamine regardless of the dose used. A disadvantaged all the papers had, was the relatively small sample sizes, so a Type I error may still be present for smaller effects on renal and organ dysfunction. This highlights the need as emphasized in all the papers for larger study sample trials to detect smaller benefits

Clinical Bottom Line

There is currently no evidence to support the use of dopexamine in critically ill patients to prevent acute renal failure

References

1. Takala J, Meier-Hellmann A, Eddleston J, Hulstaert P, Sramek V. Effect of dopexamine on outcome after major abdominal surgery: a prospective, randomized, controlled multicenter study. European Multicenter Study Group on Dopexamine in Major Abdominal Surgery. Crit Care Med 2002 ;30(8):1936-7.
2. Ralph CJ, Tanser SJ, Macnaughton PD, Sinclair DG A randomised controlled trial investigating the effects of dopexamine on gastrointestinal function and organ dysfunction in the critically ill Intensive Care Med 2002;28(7):884-90
3. Schmoelz M, Schelling G, Dunker M, Irlbeck M Comparison of systemic and renal effects of dopexamine and dopamine in norepinephrine-treated septic shock. J Cardiothorac Vasc Anaesth 2006;20(2):173-8