A 12yo boy with very high risk ALL, recent chemotherapy 4 days prior, presents to the ED with fever and lethargy. Temperature is 39C, HR 180, RR 24, BP 80/50. The patient is lethargic, has no nuchal rigidity, lungs are clear to auscultation, heart is tachycardic but regular rate and rhythm, abdominal exam is benign, and there is no rash. Pulses are bounding, there is flash capillary refill, skin is warm and dry. After adequate fluid resuscitation, cultures, and empiric antibiotics, the patient remains hypotensive. The next best treatment is:
A. Dopamine IV at 5 mcg/kg/min
B. Epinephrine IV at 0.1 mcg/kg/min
C. Norepinephrine IV at 0.1 mcg/kg/min
D. Dobutamine IV at 5 mcg/kg/min
E. Hydrocortisone 1 mg/kg IV
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November 8, 2016 at 1:05 am
Answer: C. This is a patient in warm septic shock. The majority of pediatric patients in septic shock are in cold septic shock (delayed capillary refill, cool clammy skin, weak thready pulses). Historically, dopamine at 5-10 mcg/kg/min has been used initially, but recent data suggests epinephrine at 0.1 mcg/kg/min, titrating up to effect, may be a better choice. For warm shock such as this patient has, and which is more common in adults, norepinephrine at 0.1 mcg/kg/min, titrating up to effect, is the pressor of choice. The scenario does not reveal a reason to expect adrenal deficiency.