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Inotrope / Acute Heart Failure Pregnancy: Use only for life-threatening indications — animal data shows fetal harm; limited human data

Dobutamine (Acute HF / Stress Echo)

Brand names: Dobutrex

Adult dose

Dose: Acute HF: 2.5-20 mcg/kg/min IV infusion, titrated to effect. Dobutamine stress echocardiography: 5-40 mcg/kg/min IV in staged increments every 3 minutes.
Route: Intravenous infusion via central or peripheral IV
Frequency: Continuous infusion (acute HF); staged protocol (stress echo)
Max: 20 mcg/kg/min (clinical); 40 mcg/kg/min (stress echo protocol)
Synthetic catecholamine — primarily beta-1 agonist (positive inotrope) with mild beta-2 (vasodilation) and mild alpha-1 (vasoconstriction) activity. Net effect: increased cardiac output with modest reduction in SVR. Does NOT increase HR as much as adrenaline at equivalent doses.

Paediatric dose

Dose: 5-20 mcg/min/kg
Route: IV infusion
Frequency: Continuous
Max: 20 mcg/kg/min
Specialist paediatric intensive care. Neonates: start at 5 mcg/kg/min. BNFc for guidance.

Dose adjustments

Renal

No dose adjustment required

Hepatic

No dose adjustment required

Paediatric weight-based calculator

Specialist paediatric intensive care. Neonates: start at 5 mcg/kg/min. BNFc for guidance.

Clinical pearls

  • Dobutamine vs dopamine: dobutamine primarily increases inotropy (cardiac output) with mild vasodilation. Dopamine at low doses (1-5 mcg/kg/min) increases renal perfusion (dopaminergic effect); at higher doses (5-20 mcg/kg/min) increases inotropy and HR (beta-1); at high doses (>20 mcg/kg/min) causes vasoconstriction (alpha-1). Dobutamine preferred in pure cardiogenic shock with adequate BP; noradrenaline added if BP remains low.
  • SOAP II trial: noradrenaline vs dopamine as vasopressor in shock — no overall mortality difference but dopamine caused significantly more arrhythmias. Dobutamine is NOT primarily a vasopressor (does not raise SVR).
  • Dobutamine stress echocardiography (DSE): used to assess myocardial viability (hibernating myocardium) and diagnose coronary artery disease in patients unable to exercise. Dobutamine increases heart rate and contractility — wall motion abnormalities at peak stress reveal ischaemic territories.
  • Tolerance: prolonged dobutamine infusion (>72-96 hours) causes beta-1 receptor downregulation — efficacy diminishes. Requires dose escalation or switching to alternative inotrope (milrinone, levosimendan).
  • Atropine in DSE: if target heart rate not achieved at maximum dobutamine dose, atropine 0.25-1 mg IV is added to increase heart rate. Contraindicated if narrow-angle glaucoma or severe BPH.

Contraindications

  • Hypertrophic obstructive cardiomyopathy (HOCM) — worsens LVOT obstruction
  • Uncorrected hypovolaemia (treat hypovolaemia first)
  • Pheochromocytoma
  • Hypersensitivity to dobutamine or sulphites (formulation contains sodium metabisulphite)

Side effects

  • Tachycardia (most common — dose-related)
  • Increased ventricular ectopy/arrhythmias (AF precipitation)
  • Hypertension or hypotension
  • Headache
  • Nausea
  • Tolerance with prolonged use (>72-96h — receptor downregulation)
  • Worsening myocardial ischaemia (increased O2 demand)

Interactions

  • Beta-blockers — antagonise dobutamine effect; higher doses of dobutamine may be needed if patient on chronic beta-blocker
  • MAOIs — severe hypertension; avoid combination
  • Halogenated anaesthetics — increased arrhythmia risk

Monitoring

  • Continuous ECG (arrhythmias, ischaemia)
  • Blood pressure (every 5-15 minutes)
  • Heart rate
  • Cardiac output (if PA catheter or echo)
  • Urine output

Reference: BNFc; BNF 90; BNFc; SOAP II Trial (De Backer et al. NEJM 2010); ESC Acute HF Guidelines 2021; SPC Dobutrex. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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