Inotropic support in the intensive care unit

Abstract

The benefit-risk ratio of inotropic agents is debated with drawbacks, mainly in relation to increased intracellular calcium, possibly responsible for arrhythmias and apoptosis, and increased oxygen consumption. Thus, clinical scenarios request caution when administering an inotropic agent. Dobutamine is the best first-line choice. Indications of levosimendan, a calcium fiber sensitizer still not marketed in France, remain controversial. In cardiogenic shock and cardiotoxicant poisoning, dobutamine (or isoprenaline for beta-blockers) is also the first-line agent, while high-dose insulin presents interesting effects. In contrast, in Takotsubo cardiomyopathy, dobutamine administration may be at risk: if dobutamine worsens the situation, betablockade should be preferred, concomitantly with fluids and vasopressors. In sepsis, dobutamine should be only used in case of septic cardiomyopathy or evidence for dysoxia. Beta-blockade, only tested in septic shock, seems interesting and requires further investigations. Whatever the indication is, the benefit of inotropic agent infusion should be repeatedly evaluated and stopped as soon as possible if sideeffects are evidenced.