From the Guidelines
The first-line pressor for pediatric patients with hypotension is epinephrine, given its potent inotropic and chronotropic effects, as well as its ability to increase systemic vascular resistance. Recommended starting dose: 0.05-0.3 μg/kg/min, as suggested by the American College of Critical Care Medicine 1. Administration: Epinephrine should be given via a central line or intraosseous access due to its potential to cause tissue damage if extravasation occurs. Epinephrine is preferred in children because:
- It has both alpha and beta adrenergic effects, increasing heart rate, contractility, and systemic vascular resistance.
- It's familiar to most pediatric providers and readily available in emergency situations.
- It can be effective in various types of shock (septic, cardiogenic, anaphylactic). Some key points to consider when using epinephrine in pediatric patients:
- Children <12 months may be less responsive to dopamine, making epinephrine a better choice 1.
- Recent adult data raises concerns about increased mortality with dopamine use, although the explanation for this observation is unclear 1.
- Norepinephrine is often used as a first-line agent in adults with fluid-refractory vasodilated septic shock, but children with this condition predominantly have low cardiac output, making epinephrine a more suitable choice 1. Monitor blood pressure, heart rate, and perfusion closely, and be prepared to adjust the dose or add additional pressors if the patient doesn't respond adequately. Always address underlying causes of shock (e.g., fluid resuscitation, antibiotics for sepsis) alongside vasopressor therapy.
From the FDA Drug Label
DOSAGE & ADMINISTRATION ... Begin infusion of dopamine hydrochloride solution at doses of 2 to 5 mcg/kg/min in adult or pediatric patients who are likely to respond to modest increments of heart force and renal perfusion
- Dopamine is a suggested first-line pressor for pediatric patients with hypotension, with a starting dose of 2 to 5 mcg/kg/min 2
From the Research
First-Line Pressor for Pediatric Patients with Hypotension
- The first-line pressor for pediatric patients with hypotension is epinephrine, as it has been shown to be more effective than dopamine in achieving resolution of fluid-refractory hypotensive cold shock within the first hour of resuscitation and improving organ functions 3.
- Epinephrine dosing intervals of ≤2 minutes have been associated with improved neurobehavioral outcomes compared to dosing intervals >2 minutes in pediatric in-hospital cardiac arrest patients who received at least two doses of epinephrine 4.
- Delay in administration of epinephrine has been associated with decreased chance of survival to hospital discharge, return of spontaneous circulation, 24-hour survival, and survival to hospital discharge with a favorable neurological outcome in pediatric in-hospital cardiac arrest patients with an initial nonshockable rhythm 5.
- Low-dose bolus epinephrine (≤5 µg/kg) has been used to treat acute hypotension in the PICU, resulting in a significant increase in mean arterial blood pressure and heart rate, and may provide temporary stabilization while other therapies are added or adjusted 6.
- The optimal dose of epinephrine for pediatric patients with hypotension is still a topic of debate, but current evidence suggests that high-dose epinephrine (0.1 mg/kg) may not be beneficial and may even be harmful 7.