A 7-year-old weighing 20 kg is in septic shock with HR 160/min, BP 65/40 mmHg, and cold extremities. After two normal saline boluses of 10 mL/kg each, perfusion remains poor. According to PALS 2020 guidelines, which vasoactive agent is the FIRST-LINE choice for fluid-refractory septic shock in children?
- A Norepinephrine or Epinephrine titrated to effect ✓
- B Dopamine 5–10 mcg/kg/min
- C Vasopressin 0.0003–0.002 units/kg/min
- D Phenylephrine 2–5 mcg/kg/min
Correct answer: A. Norepinephrine or Epinephrine titrated to effect
Explanation
PALS 2020 guidelines recommend norepinephrine (for warm/vasodilatory septic shock) or epinephrine (for cold/vasoconstricted septic shock) as first-line vasoactive agents for fluid-refractory septic shock in children, replacing the older recommendation of dopamine as first-line. Dopamine carries a higher risk of tachyarrhythmias and has inferior outcomes compared to norepinephrine/epinephrine in pediatric septic shock trials. Vasopressin is a second-line adjunct, and phenylephrine is avoided in children due to reflex bradycardia.
Reference: Ghai Essential Pediatrics, 10th ed.
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