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