The use of dopamine and noradrenaline in ICU patients with special reference to renal function

The discovery and recognition of the pronounced renal effects of dopamine (now more than 30 years ago) by Goldberg and colleagues, contributed to the current extensive use of dopamine in the ICU. The properties ascribed to the infusion of low-dose dopamine (i.e. enhancement or preservation of renal blood flow and increase in urine output), have made it an attractive agent for internists, anaesthesiologists, cardiologists and intensivists to support renal function. Dopamine is given to reverse the decrease in cardiac output, renal blood flow and diuresis following positive pressure ventilation with positive and expiratory pressures, to oppose the negative inotropic effects of anaesthetics, and to prevent renal failure in haemodynamically unstable patients. Dopamine is also recommended during noradrenaline infusion to protect the kidney from excessive renal vasoconstriction by noradrenaline. No controlled clinical trial, however, demonstrated an increase of survival or a decrease of renal failure from dopamine infusion therapy in the ICU, and an increasing number of reports criticise its routine use or even advocate the abandoning of dopamine from the ICU. According to a recent audit of 93 ICUs in the UK, 50% of all patients considered at risk for developing renal failure were on low-dose dopamine. Forty-three ICUs had a protocol to use dopamine in patients considered at risk of renal failure. The still widely distributed use of dopamine indicates that clinicians are not bothered by the lack of evidence of a long-lasting clinical benefit. Probably ICU physicians are focussed too much on hourly diuresis, as a marker for tissue perfusion - which is certainly provided by the strong diuretic properties of dopamine.