What is the appropriate dose of norepinephrine (vasopressor) for a 9-year-old patient (approximately 30 kg) in shock who is hypotensive and has not responded to initial fluid resuscitation?

Norepinephrine Dosing for a 9-Year-Old Child in Shock

For a 9-year-old child (approximately 30 kg) with fluid-refractory shock, start norepinephrine at 0.1 mcg/kg/min (3 mcg/min for a 30 kg child) via central venous access or intraosseous route if central access is unavailable, and titrate upward to restore normal perfusion and age-appropriate blood pressure. 1

Initial Dosing Parameters

• Starting dose: 0.1 mcg/kg/min, which equals 3 mcg/min for a 30 kg child 1
• Dosing range: 0.1-2.0 mcg/kg/min, titrated to desired clinical effect 1
• Maximum doses: Up to 5 mcg/kg/min may be necessary in exceptional circumstances, though this requires central venous access 2

Route of Administration

Central venous access is strongly preferred to minimize extravasation risk and tissue necrosis. 1, 2 However, if central access cannot be rapidly obtained:

• Peripheral IV or intraosseous (IO) administration is acceptable as a temporizing measure while establishing central access 1
• The Surviving Sepsis Campaign explicitly supports IO administration of norepinephrine in pediatric septic shock after 40-60 mL/kg of fluid resuscitation 2
• When using peripheral/IO access, administer as a dilute solution or with a carrier solution to ensure timely delivery to the heart 1
• Reduce dosage if evidence of peripheral infiltration or ischemia occurs 1

Critical Pre-Administration Requirement

Fluid resuscitation must be initiated first or concurrently with norepinephrine. 1

• Push 20 mL/kg boluses of isotonic crystalloid or 5% albumin rapidly while observing for fluid overload 1
• Children commonly require 40-60 mL/kg in the first hour, with some requiring up to 200 mL/kg 1
• Continue fluid boluses until signs of overload develop (increased work of breathing, rales, gallop rhythm, hepatomegaly) 1
• Do not delay norepinephrine if life-threatening hypotension exists—administer simultaneously with ongoing fluid resuscitation 1

Hemodynamic Goals and Titration

Target restoration of normal perfusion with these specific endpoints: 1

• Capillary refill ≤2 seconds 1
• Age-appropriate heart rate (for a 9-year-old: 70-110 bpm) 1
• Normal mental status 1
• Urine output >1 mL/kg/h 1
• Warm extremities with no differential between peripheral and central pulses 1
• ScvO2 >70% if central venous monitoring available 1
• Cardiac index 3.3-6.0 L/min/m² if advanced monitoring available 1

Titrate norepinephrine upward until these endpoints are achieved, monitoring blood pressure every 5-15 minutes during initial titration. 2

Preparation Using the "Rule of 6"

For simplified pediatric dosing preparation: 2

• Multiply 0.6 × body weight in kg = number of milligrams of norepinephrine
• For a 30 kg child: 0.6 × 30 = 18 mg
• Dilute 18 mg to a total volume of 100 mL saline
• At this concentration, 1 mL/h delivers 0.1 mcg/kg/min 2
• Starting rate would be 1 mL/h, with titration upward as needed

Escalation Strategy for Refractory Shock

If the child remains in shock despite norepinephrine: 1

• For "cold shock" (poor perfusion, cool extremities, normal or low blood pressure): Titrate epinephrine 0.05-0.3 mcg/kg/min centrally 1
• For "warm shock" (bounding pulses, warm extremities, low blood pressure): Continue titrating norepinephrine 1
• Consider hydrocortisone (1-2 mg/kg/day for stress coverage, up to 50 mg/kg/day titrated to shock reversal) if at risk for absolute adrenal insufficiency 1

Critical Safety Considerations

Extravasation management is essential: 1, 2

• If extravasation occurs, immediately infiltrate phentolamine 0.1-0.2 mg/kg (up to 10 mg) diluted in 10 mL of 0.9% sodium chloride intradermally at the site 1, 2
• This counteracts dermal vasoconstriction and prevents tissue necrosis 1

Monitor continuously for: 1

• Tachycardia, bradycardia, or arrhythmias 1
• Signs of excessive vasoconstriction (cold extremities, decreased urine output) 2
• Hypertension 1

Common Pitfalls to Avoid

• Never delay norepinephrine waiting for "complete" fluid resuscitation in life-threatening hypotension—start simultaneously 1, 3
• Do not use dopamine as first-line therapy in pediatric septic shock—norepinephrine is superior 1, 4
• Avoid inadequate fluid resuscitation before starting norepinephrine, as vasoconstriction in hypovolemia worsens organ perfusion 1, 3
• Do not mix with sodium bicarbonate or alkaline solutions in the IV line, as norepinephrine is inactivated 2
• Never administer without continuous monitoring and preparation for extravasation management 1, 2