1. We agree that digoxin is not the number one drug for treatment of heart
failure. Our article reiterates the same fact providing the scientific
basis for it.
2. It is difficult to provide a time frame as to when
to add a second drug for control of hypertension. These decisions have to
be taken by the physicians for individual patients and our article only
provides guidelines.
3. We agree with Dr Bansal that the concept of reno-protective
low dose dopamine has been challenged in several studies(1,2). As
mentioned in our article, dopamine, at low doses, increases renal blood
flow by its action on dopaminergic receptors with minimal effect on
cardiac output or heart rate(3). Dopamine infusion has been shown to
increase renal plasma flow during norepinephrine administration in
adults(4,5). Two recent reports have further confirmed the beneficial
effect of low dose dopamine on renal blood flow(6,7). Dopamine continues
to be used in routine practice especially following cardiopulmonary
bypass.
4. Regarding his comment on adverse effect of dopamine
on gastric mucosal pH, increase in pulmonary shunt and immunosuppression,
we would be very interested in the exact cross references.
5. The septic shock patients are hypotensive by
definition and hence the algorithm is catered towards such cases. The
comment on high SVR shock is well taken.
References
1. Prins I, Plotz FB, Uiterwaal CS, van Vught HJ.
Low-dose dopamine in neonatal and pediatric intensive care: A systematic
review. Intensive Care Med 2001; 27: 206-210.
2. Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh
J. Low-dose dopamine in patients with early renal dysfunction: A
placebo-controlled randomized trial. Australian and New Zealand Intensive
Care Society (ANZICS) Clinical Trials Group. Lancet 2000; 356: 2139-2143.
3. MacGregor DA, Prielipp RC, Black CS, Kennedy DJ,
Browder RW, Butterworth JF 4
th,
Renal dose dopamine does not alter the response to beta adrenergic
stimulation by isoproterenol in healthy human volunteers. Chest 1997; 112:
40-44.
4. Richer M, Robert S, Lebel M. Renal hemodynamics
during nor-epinephrine and low dose dopamine infusions in man. Crit Care
Med 1996; 24:1150-1156.
5. Hoogenberg K, Smit AJ, Girbes AR. Effects of low
dose dopamine on renal and systemic hemodynamicsduring incremental
norepinephrine infusion in healthy volunteers. Crit Care Med 1998; 26:
260-265.
6. Drieghe B, Manoharan G, Hevndrickx GR, Madaric J,
Bartunek J, Sarno G, et al. Dopamine induced changes in renal blood
flow in normals and in patients with renal dysfunction. Cathet Cardiovasc
Interv 2008; 72: 725-730.
7. Ungar A, Fumagalli S, Marini M, Di Serio C,
Tarantini F, Boncinelli L, et al. Renal, but not systemic,
hemodynamic effects of dopamine are influenced by the severity of
congestive heart failure. Crit Care Med 2004; 32: 1125-1129.