A 5-year-old presents in septic shock with cold peripheries, capillary refill time 5 seconds, BP 65/40 mmHg, and HR 165/min. After two 20 mL/kg IV fluid boluses with no improvement, which agent should be started first?
- A Noradrenaline (norepinephrine)
- B Dobutamine
- C Dopamine or adrenaline (epinephrine) ✓
- D Vasopressin
Correct answer: C. Dopamine or adrenaline (epinephrine)
Explanation
In pediatric fluid-refractory septic shock, dopamine (5–10 mcg/kg/min) or adrenaline (0.05–0.3 mcg/kg/min) is the first-line vasoactive agent per ACCM/Surviving Sepsis pediatric guidelines. Cold shock (vasoconstricted, low CO) responds to adrenaline/dobutamine + noradrenaline; warm shock to noradrenaline. However, in children without a clear warm vs cold distinction and with fluid refractoriness, dopamine or adrenaline is the initial choice before differentiating further. Vasopressin is a second-line refractory agent.
Reference: Ghai Essential Pediatrics, 10th ed.
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