Winkler M J, Trunkey D D
Am J Surg. 1981 Nov;142(5):588-91. doi: 10.1016/0002-9610(81)90432-3.
Multiple extremity gangrene developed in five patients as a complication of dopamine therapy. The clinical conditions were (1) penetrating chest trauma requiring pneumonectomy with postoperative sepsis, (2) cardiac arrest with aspiration pneumonia, (3) lymphoma with sepsis, (4) Klebsiella pneumonia, and (5) myocardial infarction. The development of acrocyanosis leading to gangrene occurred at dopamine dosages of 5.1 to 10.2 micrograms/kg/min. The alpha-adrenergic vasoconstriction effects of dopamine would not be expected from the doses employed in these patients. Thus, other factors beside pure alpha vasoconstriction are responsible for tissue necrosis after the use of dopamine. We believe that the embolic complications of disseminated intravascular coagulation and hypovolemia are serious risk factors in the development of dopamine gangrene. Peripheral vasoconstriction from dopamine, even at low doses, may set the stage for thrombotic complications of disseminated intravascular coagulation and lead to tissue damage. In laboratory models of disseminated intravascular coagulation, an alpha-adrenergic drug is required to produce peripheral ischemic tissue damage. Treatment of tissue ischemia related to dopamine depends on early recognition of acrocyanosis. Phentolamine, an alpha blocker, has been recommended for treating dopamine ischemia, either through local instillation into ischemic tissues or intravenous infusion. We recommend a high index of suspicion for, and early treatment of, underlying consumptive coagulopathy in all patients requiring dopamine.
5例患者在多巴胺治疗过程中出现多肢坏疽并发症。临床情况分别为：（1）穿透性胸部创伤需行肺切除术并术后发生败血症；（2）心脏骤停合并吸入性肺炎；（3）淋巴瘤合并败血症；（4）克雷伯菌肺炎；（5）心肌梗死。在多巴胺剂量为5.1至10.2微克/千克/分钟时出现导致坏疽的肢端发绀。从这些患者所使用的剂量来看，多巴胺的α-肾上腺素能血管收缩作用是无法预期的。因此，除了单纯的α血管收缩外，其他因素也与使用多巴胺后的组织坏死有关。我们认为，弥散性血管内凝血和血容量不足的栓塞并发症是多巴胺性坏疽发生的严重危险因素。即使是低剂量的多巴胺引起的外周血管收缩，也可能为弥散性血管内凝血的血栓形成并发症创造条件并导致组织损伤。在弥散性血管内凝血的实验室模型中，需要一种α-肾上腺素能药物来造成外周缺血性组织损伤。与多巴胺相关的组织缺血的治疗取决于对肢端发绀的早期识别。酚妥拉明，一种α受体阻滞剂，已被推荐用于治疗多巴胺所致的缺血，可通过局部注入缺血组织或静脉输注。我们建议对所有需要使用多巴胺的患者，高度怀疑并早期治疗潜在的消耗性凝血病。
