Inotrope · Catecholamine
Dobutamine
Indications
- Short-term inotropic support for low output from depressed contractility (label): decompensated heart failure, cardiogenic shock once MAP is supported
- Septic shock with hypoperfusion from myocardial dysfunction despite adequate volume and MAP (SSC)
- Low output after cardiac surgery, and RV failure after volume loading
- Bridge to transplant or mechanical support, or palliative home infusion (off-label)
- Pharmacologic stress echocardiography (off-label)
Dosing
Dobutamine drip card and mL/h converterStart: 2–5 mcg/kg/min (label starts 0.5–1)
Mechanism of action
Dobutamine is a synthetic catecholamine that acts mainly on β1 receptors: Gs-coupled adenylyl cyclase raises cAMP, and protein kinase A phosphorylates L-type calcium channels, phospholamban and troponin I, so contraction strengthens and relaxation speeds. It is racemic: the (+) isomer is a β1 and β2 agonist and α1 antagonist, the (−) isomer an α1 agonist, so vascular α1 and β2 effects largely cancel, leaving inotropy with mild vasodilation. It neither releases norepinephrine nor acts on dopamine receptors.
Pharmacology
- Cardiovascular: raises stroke volume and cardiac output and lowers wedge pressure and SVR; heart rate rises less than with isoproterenol, though by 30 bpm or more in 10% (label)
- Cardiovascular: speeds AV conduction (faster ventricular rate in AF) and raises myocardial O₂ demand, the basis of stress echocardiography
- Cardiovascular: BP may fall with hypovolemia (β2 vasodilation) or rise; systolic rose 50 mm Hg or more in 7.5% (label)
- Renal: urine output rises only through better cardiac output (no D1 effect)
- Metabolic: β2 shifts K⁺ into cells (hypokalemia)
- Other: tolerance after about 72 h as β receptors downregulate
Pharmacokinetics
| Onset | 1–2 min IV (label) |
|---|---|
| Peak | Up to 10 min (label) |
| Half-life | About 2 min (label; 2.4 min in severe heart failure) |
| Distribution | Vd about 0.2 L/kg, larger with edema (Kates 1978) |
| Metabolism | COMT methylation to inactive 3-O-methyldobutamine, and conjugation (label) |
| Clearance | About 2.4 L/min/m² (Kates 1978) |
| Elimination | Urine, as conjugates of dobutamine and 3-O-methyldobutamine (label) |
Chemistry
- Synthetic catecholamine: dopamine with a bulky 3-(4-hydroxyphenyl)-1-methylpropyl group on the amine, which adds β1 selectivity and removes indirect action; no β-hydroxyl
- One chiral center, given racemic because the enantiomers' opposing α1 actions balance (Ruffolo 1987)
- Premixed 1, 2 or 4 mg/mL in D5W with sodium metabisulfite and edetate, pH 2.5–5.5 (label)
- A pink tint from slight oxidation does not mean lost potency (label); do not mix with sodium bicarbonate or other strong alkalis
Adverse effects and cautions
In the one-pagers
- Vasopressors and InotropesReceptors and effects: Dobutamine: β1 > β2: ↑ / ↑↑ / ↓
- Right Heart Failure and Pulmonary HypertensionManagement priorities: Contractility: dobutamine or milrinone, usually with a pressor.
- Sepsis and Septic Shock BundleVasopressors and MAP: Cardiac dysfunction: Add dobutamine, or epi alone: Low output despite fluids and pressors
- Endocarditis and Valve EmergenciesValve emergencies: LVOT obstruction: SAM; worse on dobutamine; systolic murmur: Stop inotropes; fluid, esmolol, phenylephrine
- Heart FailureDecompensated HF and shock: Cardiogenic shock: SBP <90 mm Hg for >30 min or pressors needed, plus hypoperfusion (urine <30 mL/h, lactate >2 mmol/L); typically CI <2.2 and PCWP >15. Revascularize if MI. Norepinephrine for hypotension, plus an inotrope (dobutamine or milrinone) for low output. Temporary MCS (e.g., Impella, VA-ECMO) if drugs fail; routine IABP or ECMO is not advised
- ACS and STEMIMechanical complications, RV infarction and shock: RV infarction accompanies up to 40% of inferior STEMIs (LITFL). V4R elevation marked 31% vs 6% in-hospital mortality (Zehender 1993) and fades within 10 h in half of patients. Expect hypotension, clear lungs and raised JVP, with RAP ≥10 mm Hg close to the wedge (RAP:PCWP ≥0.8). Reperfuse; no nitrates or diuretics; fluid in 250–500 mL steps while o
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Sources
- FDA label: dobutamine in dextrose (2026)
- Kates and Leier 1978 (kinetics)
- Ruffolo 1987 (enantiomers)
For education and exam preparation only. Follow your institution’s protocols. Typical adult values for study. Follow the order, the label and your institution's protocols.