Dopamine versus dobutamine for hypotensive preterm infants

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Abstract
Inotropes are widely used in preterm infants to treat systemic hypotension. The most commonly used drugs are dopamine and dobutamine. These agents have different modes of action which may result in different haemodynamic effects. To compare the effectiveness and safety of dopamine and dobutamine in the treatment of systemic hypotension in preterm infants. Searches of electronic and other databases were performed including MEDLINE (1966-2002), EMBASE (1988-2002), Science Citation Index (1981-2002), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2003). Previous reviews were searched for references to relevant trials and leading authors in the field were contacted for information about other published and unpublished studies. Randomised controlled trials where short and/or long term effects of treatment with dopamine and dobutamine for the treatment of systemic arterial hypotension were compared were selected for this review. Trials studying newborn infants born before 37 completed weeks gestation and less than 28 days of age were eligible for inclusion. Systemic arterial hypotension was not defined specifically, but accepted as defined in individual studies. Studies were not limited by birthweight, lower gestational age threshold or by route or duration of administration of inotropic agents. Study quality and eligibility were assessed independently by each reviewer. Data extraction was performed independently by each reviewer, with differences being resolved by discussion. The following outcomes were determined: mortality in the neonatal period, long term neurodevelopmental outcome, radiological evidence of severe neurological injury, short term haemodynamic changes and incidence of adverse effects. The effect of interventions was expressed either as Relative Risk (RR), Risk Difference (RD) or as Weighted Mean Difference (WMD) with their 95% Confidence Interval (CI). Five trials met the pre-defined criteria for inclusion in this review. There was no evidence of a significant difference between dopamine and dobutamine in terms of neonatal mortality (RD 0.02 95% CI -0.12 to 0.16), incidence of periventricular leukomalacia (RD -0.08, 95% CI -0.19 to 0.04), or severe periventricular haemorrhage (RD -0.02, 95% CI -0.13 to 0.09). Dopamine was more successful than dobutamine in treating systemic hypotension, with fewer infants having treatment failure (RD -0.23, 95% CI -0.34 to -0.13; NNT = 4.4, 95% CI 2.9 to 7.7). Treatment with dobutamine was associated with a significantly greater increase in left ventricular output in the single study reporting that outcome. There was no evidence of a significant difference between the two agents with respect to the incidence of tachycardia (RD -0.06, 95% CI -0.25 to 0.14). None of the studies reported the incidence of adverse long term neurodevelopmental outcome. Dopamine is more effective than dobutamine in the short term treatment of systemic hypotension in preterm infants. There was no evidence of an effect on the incidence of adverse neuroradiological sequelae (severe periventricular haemorrhage and/or periventricular leucomalacia), or on the incidence of tachycardia. However, in the absence of data confirming long term benefit and safety of dopamine compared to dobutamine, no firm recommendations can be made regarding the choice of drug to treat hypotension. Dopamina versus dobutamina para recién nacidos prematuros hipotensos Los inotrópicos se utilizan ampliamente en los recién nacidos prematuros para tratar la hipotensión sistémica. Los fármacos de uso más frecuente son la dopamina y la dobutamina. Estos agentes tienen diferentes modos de acción que pueden producir diferentes efectos hemodinámicos. Comparar la efectividad y la seguridad de la dopamina y la dobutamina en el tratamiento de la hipotensión sistémica en los recién nacidos prematuros. Se realizaron búsquedas en bases de datos electrónicas y otras que incluyeron MEDLINE (1966 a 2002), EMBASE (1988 a 2002), Science Citation Index (1981a 2002), el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials) (CENTRAL, La Cochrane Library, Número 2, 2003). Se buscaron referencias de ensayos relevantes en las revisiones anteriores, y se estableció contacto con los autores principales en el tema para obtener información sobre otros estudios publicados y no publicados. Para esta revisión se seleccionaron ensayos controlados aleatorios donde se comparaban los efectos a corto o a largo plazo del tratamiento con dopamina y dobutamina para tratar la hipotensión arterial sistémica. Fueron elegibles para su inclusión los ensayos que estudiaron recién nacidos de menos de 37 semanas completas de gestación y de menos de 28 días de vida. La hipotensión arterial sistémica no se definió de manera específica, pero se aceptó la definición de los estudios individuales. Los estudios no estuvieron limitados por el peso al nacer, el umbral inferior de edad gestacional o la vía o duración de la administración de los agentes inotrópicos. Cada revisor evaluó en forma independiente la calidad y la elegibilidad de los estudios. Cada revisor obtuvo los datos de forma independiente y las diferencias se resolvieron mediante discusión. Se determinaron los siguientes resultados: mortalidad en el período neonatal, resultado del desarrollo neurológico a largo plazo, pruebas radiológicas de lesión neurológica grave, cambios hemodinámicos a corto plazo e incidencia de efectos adversos. El efecto de las intervenciones se expresó como Riesgo Relativo (RR), Diferencia de Riesgo (DR) o Diferencia de Medias Ponderada (DMP) con su Intervalo de Confianza...