Early inotropic support in pediatric shock: evidence and challenges in prehospital setting and interfacility transport

Background & aim: Pediatric shock requires rapid recognition and timely intervention. In the prehospital and interfacility transport setting, the challenge is further compounded by limited vascular access, limited monitoring capabilities, and the need for rapid decision-making in dynamic, resource-constrained environments. The aim of this review is to summarize the available literature on the use of vasoactive agents in pediatric shock, provide guidance for evidence-based decision-making, and identify key gaps for future research. Methods: A literature search was conducted using electronic databases, including PubMed and Medline. Only articles published in peer-reviewed journals, written in English, and focusing on the use of vasoactive drugs in the pediatric population were selected, bringing the total number of articles selected to 63, of which 21 were original studies (randomized or observational). Two independent reviewers extracted the data, which were then organized thematically in a narrative synthesis given study heterogeneity. Results: This review provides a comprehensive summary of the current evidence regarding vasoactive support in pediatric shock in the prehospital and transport setting. Although fluid administration is the first therapeutic step, there is a growing trend towards early initiation of inotropic/vasoactive agents. Overall, epinephrine and norepinephrine remain the agents of choice for fluid-refractory pediatric shock. Inodilators may offer potential benefit in selected patients with myocardial dysfunction. Evidence regarding adjunctive therapies, such as vasopressin, terlipressin, and catecholamine-sparing agents, remains limited. Available evidence supports the feasibility and safety of timely vasoactive support via peripheral and intraosseous routes with dilute preparations of vasoactive agents. Conclusions: In the context of prehospital and transport settings, central venous catheterization is no longer a prerequisite, and early initiation of inotropic/vasoactive therapy, which is increasingly suggested by literature in different clinical scenarios, may improve outcomes in critically ill children.