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Pediatric Vasoactive Drug Administration

Indications:

  • Hemodynamic compromise
  • Circulatory compromise

Clinical Data:

Inotropic support should be considered only after adequate fluid resuscitation.

NOTE: Use large vein to prevent possibility of extravasation.

Guidelines:

  1. Administer on infusion pump.
  2. Document infusion concentration, drip rate, and medication dose in mcg/kg/minute on the transfer record.
  3. Start at low end or middle range of recommended dose, titrate per desired effect and monitor for undesirable effects.
  4. If hemodynamic/circulatory compromise persists after adequate fluid resuscitation, initiate vasoactive therapy:
    1. Dopamine (Premix 800mg/250mL)
      1. 2-20 mcg/kg/minute: Dose related effects.
      2. Recommended primarily for hypotension and shock for inotropic effects.
      3. 2-5 mcg/kg/minute: Primarily dopaminergic
      4. 5-10 mcg/kg/minute: Inotropic beta effects
      5. 10-20 mcg/kg/minute: Vasoconstrictive effects with increasing alpha effects
      6. More than 20 mcg/kg/minute: not indicated as it may cause increased myocardial oxygen consumption and offset desirable effects.
    2. Norepinephrine (Levophed)
      1. < 40 kg: 0.01 – 1 mcg/kg/minute, titrate to desired effect. Max dose 2 mcg/kg/minute.
      2. ≥ 40 kg: 0.5 - 1 mcg/minute, titrate to desired effect. Max dose 30 mcg/min
      3. For treatment of warm shock refractory to fluid and Dopamine
      4. Strong alpha effects (vasoconstriction) and less beta effects (inotropic and chronotropic)
      5. NOTE: Not recommended for dilution in normal saline.
    3. Epinephrine
      1. < 50 kg: 0.05 – 1 mcg/kg/minute
      2. ≥ 50 kg: 1 – 10 mcg /min
      3. Potent alpha effects with vasoconstriction, increased heart rate, and blood pressure.
      4. Recommended for cold shock (decreased SVR)
      5. NOTE: In patients with congenital heart diseases, high dose Epinephrine or Norepinephrine can be detrimental.

Citations/References:

  1. Bierley J, Carcillo J, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009; 37(2):666–688.