A 9-year-old in septic shock has received 40 mL/kg of isotonic crystalloid. She remains hypotensive with wide pulse pressure, warm flushed peripheries, bounding pulses, and capillary refill under 2 seconds. Which vasoactive agent should be started first?
- A Norepinephrine ✓
- B Dopamine
- C Epinephrine
- D Vasopressin
Correct answer: A. Norepinephrine
Explanation
Warm or distributive shock reflects predominant vasodilation with a wide pulse pressure and bounding pulses, so the first-line agent is norepinephrine, an alpha-dominant vasopressor that restores systemic vascular resistance. Epinephrine is first-line in cold shock with low cardiac output, the profile seen in younger children. Vasopressin is a second-line rescue agent, not an initial choice. Dopamine has largely fallen out of favor due to arrhythmia risk.
Reference: Nelson Textbook of Pediatrics, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.