Scandinavian SSAI clinical practice guideline on choice of inotropic agent for patients with acute circulatory failure

• Published in: Acta anaesthesiologica Scandinavica 2018-04, Vol.62 (4), p.420-450
• Main Authors: Møller, M. H., Granholm, A., Junttila, E., Haney, M., Oscarsson‐Tibblin, A., Haavind, A., Laake, J. H., Wilkman, E., Sverrisson, K. Ö., Perner, A.
• Format: Article
• Language: English
• Subjects: Acute Disease; Anesthesiology; Cardiac output; cardiogenic shock; Cardiotonic Agents - therapeutic use; Clinical practice guidelines; Critical Care; decompensated heart failure; dobutamine; Dobutamine - therapeutic use; Epinephrine; grade; Heart; Heart diseases; Heart surgery; Humans; levosimendan; low cardiac output; metaanalysis; Patients; Practice Guidelines as Topic; Review; Septic shock; Shock - drug therapy; Societies, Medical; Subpopulations; Surgery; trial sequential analysis
• ISSN: 0001-5172; 1399-6576; 1399-6576
• DOI: 10.1111/aas.13089

Background Adult critically ill patients often suffer from acute circulatory failure and those with low cardiac output may be treated with inotropic agents. The aim of this Scandinavian Society of Anaesthesiology and Intensive Care Medicine guideline was to present patient‐important treatment recommendations on this topic. Methods This guideline was developed according to GRADE. We assessed the following subpopulations of patients with shock: (1) shock in general, (2) septic shock, (3) cardiogenic shock, (4) hypovolemic shock, (5) shock after cardiac surgery, and (6) other types of shock, including vasodilatory shock. We assessed patient‐important outcome measures, including mortality and serious adverse reactions. Results For all patients, we suggest against the routine use of any inotropic agent, including dobutamine, as compared to placebo/no treatment (very low quality of evidence). For patients with shock in general, and in those with septic and other types of shock, we suggest using dobutamine rather than levosimendan or epinephrine (very low quality of evidence). For patients with cardiogenic shock and in those with shock after cardiac surgery, we suggest using dobutamine rather than milrinone (very low quality of evidence). For the other clinical questions, we refrained from giving any recommendations or suggestions. Conclusions We suggest against the routine use of any inotropic agent in adult patients with shock. If used, we suggest using dobutamine rather than other inotropic agents for the majority of patients, however, the quality of evidence was very low, implying high uncertainty on the balance between the benefits and harms of inotropic agents.