What is the recommended protocol for administering a dopamine drip in pediatric patients?

Administering Dopamine Drip in Pediatric Patients

For hypotension refractory to volume replacement and epinephrine injections in pediatric patients, dopamine can be administered intravenously at 2 to 20 mcg/kg/min, with the rate titrated to maintain adequate blood pressure. 1

Preparation and Administration

• Prepare dopamine infusion using the "rule of 6": 0.6 × body weight (kg) = number of milligrams diluted to total 100 mL of saline; then 1 mL/h delivers 0.1 mcg/kg/min 1
• Alternatively, prepare a standard solution of 400 mg dopamine in 500 mL D5W 1
• Administer through a secure intravenous line, preferably into a large vein to prevent infiltration of perivascular tissue 2
• Use an infusion pump, preferably a volumetric pump, rather than gravity-regulated administration 2
• Continuous hemodynamic monitoring is essential during dopamine administration 1

Dosing Guidelines

• Initial dose: Begin infusion at 2-5 mcg/kg/min in pediatric patients who are likely to respond to modest increments of heart force and renal perfusion 2
• For more seriously ill patients: Start at 5 mcg/kg/min and increase gradually using 5-10 mcg/kg/min increments up to 20-50 mcg/kg/min as needed 2
• Typical therapeutic range: 2-20 mcg/kg/min, titrated to maintain systolic blood pressure >90 mmHg (or age-appropriate target) 1
• Dosing effects are concentration-dependent 1:
  • Low doses (<5 mcg/kg/min): Primarily dopaminergic effects (renal and mesenteric vasodilation)
  • Intermediate doses (5-10 mcg/kg/min): β-adrenergic effects (increased cardiac contractility)
  • Higher doses (>10 mcg/kg/min): α-adrenergic effects (peripheral vasoconstriction) 3

Monitoring

• Continuous monitoring of vital signs including blood pressure, heart rate, and ECG 1
• Monitor urine output hourly 2
• Check for signs of extravasation at the infusion site 2
• Assess peripheral perfusion regularly 1
• Consider arterial lactate and central venous oxygen saturation to assess tissue oxygen delivery 1

Special Considerations for Pediatric Patients

• Neonates may have diminished inotropic response compared to older children due to maturational differences in norepinephrine stores 3
• Clearance varies widely in the pediatric population depending on age 3
• Elimination half-life is approximately 2 minutes in full-term neonates and older children, but may be as long as 4-5 minutes in preterm infants 3
• Recent evidence suggests epinephrine may be preferable to dopamine as first-line therapy in pediatric septic shock 4

Cautions and Adverse Effects

• Diminution of established urine flow rate, increasing tachycardia, or development of new dysrhythmias are reasons to consider decreasing or temporarily suspending the dosage 2
• Infusion rates >20 mcg/kg/min may result in excessive vasoconstriction 1
• Common adverse effects include tachycardia and cardiac arrhythmias, especially at higher doses 3
• Extravasation may cause tissue necrosis and sloughing 2
• Avoid concomitant use with butyrophenones, phenothiazines, vasopressors, and vasoconstricting agents as they may result in severe hypertension 2
• Administration of phenytoin to patients receiving dopamine has been reported to lead to hypotension and bradycardia 2

When to Consider Alternative Agents

• If dopamine is ineffective at improving hemodynamics at maximum doses 2
• In infants with marked circulatory instability and decompensated shock, epinephrine or norepinephrine may be preferable 1
• For pediatric septic shock, recent evidence suggests epinephrine may be associated with better outcomes than dopamine 4
• Low-dose dopamine for renal protection lacks sufficient evidence in pediatric patients and should be reconsidered 5, 6