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children with fluid-refractory, catecholamine-resistant septic shock. However, in a
multicenter trial of 65 children with vasodilatory shock, low-dose vasopressin did
not decrease the time to hemodynamic stability off of vasoactive agents versus
placebo (49.7 vs. 47.1 hours) and there was a concerning trend toward increased
mortality in the vasopressin group (30% vs. 16%, p = 0.24).
TABLE 10.4
VASOACTIVE AGENTS

For patients with “cold” shock, priority should be given to improving cardiac
contractility with inotropes. First-line therapy with epinephrine is recommended.
Addition of norepinephrine or dopamine may be considered for ongoing
hypotension despite titration of epinephrine. Once the patient is transferred to the
ICU, ScvO2 is often monitored. If ScvO2 remains <70% in septic shock, addition
of agents with additional inotropic properties along with afterload reduction
(dobutamine, milrinone) may also be helpful.
In the setting of myocardial dysfunction, such as cardiogenic shock from
myocarditis, early initiation of inotropic therapy with epinephrine and/or
dopamine should be considered. These agents should be carefully titrated, as they
may contribute to arrhythmias and increase myocardial oxygen demand.