intravenous epinephrine infusion should be strongly considered. For patients with
persistent shock despite fluid resuscitation and inotropic support, adrenal
insufficiency should be suspected. In this situation, hydrocortisone (2 mg/kg)
should be administered once baseline ACTH levels (any room for urine cortisol
levels? have been obtained (need better dosing for hydrocortisone)
Specific Vasoactive Agents
Dopamine is a catecholamine that improves cardiac contractility but which
can also improve splanchnic, cerebral and coronary blood flow. There remains
controversy regarding dopamine’s ability to improve renal perfusion. In infants
and children with hypotension, dopamine is a preferred initial inotropic choice
due to its alpha-adrenergic effects at higher doses. Acceptable doses range from
2 - 20 μg/kg/minute.
Dobutamine, another catecholamine, has gained popularity due to its
ability to improve cardiac performance at various levels, including chronotropy,
contractility, and afterload reduction. Dobutamine reduces the degradation of
cylic AMP (cAMP). Thus, cAMP is more available to the myocardium.
Dobutamine is thought to be less arrhythmogenic than other inotropic agents.
Although dobutamine can reduce afterload, cardiac function may not be
improved without a concomitant increase in blood pressure. In this circumstance,
another medication may be required to increase blood pressure if hypotension
occurs after the introduction of dobutamine. In cases of increased systemic and
pulmonary vascular resistance, milrinone, in synergy with dobutamine, may be