Agents
| Agent |
Dose range |
Mechanism |
Primary role |
Key limitation |
| Dopamine |
2-20 mcg/kg/min |
Dopaminergic effect at 2-5 mcg/kg/min, beta effect at 5-10, alpha effect above 10 |
Chronotropic support in bradycardic shock |
Response is unpredictable between patients and does not separate cleanly by dose |
| Dobutamine |
2-20 mcg/kg/min |
Beta-agonist inotropy with vasodilation |
Cardiogenic shock with preserved blood pressure |
Vasodilation can drop pressure; frequently requires a paired vasopressor |
| Epinephrine |
0.01-1+ mcg/kg/min |
Beta-dominant at 0.01-0.1 mcg/kg/min, alpha-dominant at higher doses |
Combined inotropy and vasoconstriction in one infusion |
High doses raise heart rate and myocardial oxygen demand, increase arrhythmia risk, and prolonged use causes lactic acidosis |
| Norepinephrine |
0.01-1+ mcg/kg/min |
Alpha-dominant vasoconstriction with preserved beta/contractility |
First-line vasopressor for septic and other vasodilatory shock [1] |
Requires a central line; less tachycardia than epinephrine but not free of it |
| Milrinone |
0.25-0.75 mcg/kg/min |
Phosphodiesterase inhibitor; inotropy plus systemic and pulmonary vasodilation |
Post-op low cardiac output syndrome, and pulmonary hypertension layered on heart failure [2] |
Vasodilation can reduce systemic pressure; often paired with a vasopressor |
Caution. Renal-dose dopamine (2-5 mcg/kg/min) does not protect renal function despite the theoretical basis for the practice, and dopamine's effects vary unpredictably between patients at any given dose.
Clinical pearl. Dopamine's main remaining role in the PICU is chronotropic support for bradycardic shock, not routine first-line pressor use.
Scoring
VIS = Dopamine + Dobutamine + (100 × Epinephrine) + (100 × Norepinephrine) + (10 × Milrinone) + (10,000 × Vasopressin)
- All catecholamine doses are entered in mcg/kg/min; vasopressin in U/kg/min.
- The weighting reflects the relative potency of each agent: epinephrine and norepinephrine are weighted 100-fold, vasopressin 10,000-fold.
- Higher VIS correlates with greater illness severity and worse prognosis [3].
- A rising VIS during ongoing resuscitation indicates the patient is not responding to current management; a falling VIS, even gradually, generally indicates recovery.
- VIS is used for team communication, quality metrics, and research standardization [3].
Open the VIS Score Calculator →
Management
Combine agents by matching the drug to the dominant physiologic problem:
- Septic shock with poor contractility: norepinephrine as the primary vasopressor, with low-dose dobutamine added for inotropy if ejection fraction is reduced [1].
- Cardiogenic shock: dobutamine or milrinone for combined inotrop
References
- Weiss SL, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020;21(2):e52-e106. doi:10.1097/PCC.0000000000002198
- Hoffman TM, et al. Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation. 2003;107(7):996-1002. doi:10.1161/01.CIR.0000051365.81920.28
- Gaies MG, Gurney JG, Yen AH, et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med. 2010;11(2):234-238. doi:10.1097/PCC.0b013e3181b806fc