Noradrenaline Infusion Rate in Pediatric Post-Cardiac Arrest
For pediatric patients after return of spontaneous circulation (ROSC) following cardiac arrest, norepinephrine infusion should be started at 0.1 mcg/kg/min and titrated up to 2 mcg/kg/min to maintain systolic blood pressure above the age-specific 10th percentile during the first 6 hours post-ROSC 1.
Post-ROSC Hemodynamic Management
The primary goal after achieving ROSC is maintaining adequate perfusion pressure to vital organs while avoiding both hypotension and excessive vasoconstriction.
Blood Pressure Targets
During the first 6 hours after ROSC:
- Maintain systolic blood pressure above the age-specific 10th percentile 1
- This is the critical window for preventing secondary brain injury
If invasive arterial monitoring is available during ongoing CPR:
- Target diastolic blood pressure ≥25 mmHg in infants
- Target diastolic blood pressure ≥30 mmHg in children ≥1 year old 2
Vasopressor Selection
The 2020 AHA guidelines specifically state that epinephrine or norepinephrine infusions are used for fluid-refractory septic shock 3. While this recommendation is made in the context of sepsis, it applies to post-cardiac arrest shock management.
Norepinephrine dosing from FDA labeling 4:
- Initial rate: 0.5-1 mL/min of standard dilution (2-4 mcg/min base for adults)
- Pediatric equivalent: 0.1-2 mcg/kg/min 1
- Titrate to maintain adequate blood pressure
- Requires continuous hemodynamic monitoring
Alternative Vasopressors
If norepinephrine alone is insufficient, consider these options 1:
Epinephrine:
- 0.1-1 mcg/kg/min IV/IO
- Provides both inotropic and vasopressor effects
- Higher risk of tachyarrhythmias and peripheral vascular injury
Dopamine:
- 2-20 mcg/kg/min IV/IO
- Lower doses (2-5 mcg/kg/min): renal and splanchnic vasodilation
- Higher doses (>10 mcg/kg/min): vasopressor effects
- Also carries risk of tachyarrhythmias
Dobutamine:
- 2-20 mcg/kg/min IV/IO
- Pure inotrope with vasodilatory properties
- Use when cardiac output is low but vascular resistance is adequate
Critical Implementation Points
Timing and Monitoring
- Initiate vasopressor support immediately if hypotension persists after adequate fluid resuscitation
- Continuous arterial blood pressure monitoring is essential 4
- Central venous access is strongly preferred to minimize risk of extravasation injury 4
Common Pitfalls to Avoid
Inadequate fluid resuscitation first: Always ensure adequate volume status before escalating vasopressor doses. Occult hypovolemia is a frequent cause of refractory hypotension 4
Delayed initiation: Post-cardiac arrest hypotension significantly worsens neurological outcomes. Start vasopressors promptly when blood pressure targets are not met with fluids alone
Peripheral IV administration: Norepinephrine is a potent vasoconstrictor. Extravasation causes severe tissue necrosis. Use central or intraosseous access 4
Abrupt discontinuation: Taper vasopressors gradually to avoid rebound hypotension 4
Emerging Evidence
Recent research suggests norepinephrine may have advantages over epinephrine in post-cardiac arrest care. A 2021 retrospective study found that adult patients receiving initial norepinephrine had lower rates of refractory shock, rearrest, or death in the emergency department compared to epinephrine (22.2% vs 50%, adjusted OR 3.94) 5. A 2025 ongoing pediatric RCT is specifically comparing norepinephrine to epinephrine for post-cardiac arrest shock, examining mortality, vasopressor duration, and neurological outcomes 6.
Special Considerations
During active CPR (before ROSC):
- Epinephrine remains the primary vasopressor: 0.01 mg/kg IV/IO every 3-5 minutes 3
- Vasopressin is not routinely recommended but may be considered in refractory cases 7, 8
Post-ROSC transition:
- Switch from bolus epinephrine to continuous infusion (epinephrine or norepinephrine) once ROSC is achieved and hypotension persists despite fluid resuscitation
- The choice between epinephrine and norepinephrine infusions should be based on the specific hemodynamic profile, with norepinephrine preferred when pure vasopressor support is needed