Use of norepinephrine in the pediatric intensive care unit: an international survey of prescription and administration habits in case of pediatric hypotensive shock.

This international survey aimed to describe worldwide norepinephrine prescription habits in pediatric intensive care units (PICU) in case of hypotensive shock. We sought to identify reporting Querydiscrepancies regarding dosing units and conjugated salts of norepinephrine. Between November 1, 2023, and February 10, 2024, a cross-sectional electronic survey was emailed to PICU prescribers through the following networks: PICURe (French-speaking countries), ESPNIC (Europe), Be-PICS (Belgium), PALISI (America), PACCMAN (Asia), JSPICC (Japan), and ANZICS PSG (Oceania). The survey was developed by a specialized clinical pharmacist and a pediatric intensivist and independently validated by three French- and English-speaking pediatric intensivists and a specialized clinical pharmacist. We received 541 responses, of which 424 were complete (78.4%) (center response rate 60.2%). A total of 199 ((46.9%) [42.2-51.7%]) were from Europe, 144 ((34.0%) [29.6-38.6%]) and 70 ((16.5%) [13.3-20.3%]) from Asia/Middle East, and 11 ((2.6%) [1.5-4.6%]) from Oceania. The respondents were mainly attending pediatric intensivists ((81.4%) [77.4-84.8%]). 43.9% [39.2-48.6%] of respondents did not know what type of norepinephrine formulation they used. Respondents reported norepinephrine dosing in terms of norepinephrine base ((46.2%) [41.5-51.0%]) or norepinephrine conjugated salt ((17.7%) [14.4-21.6%]), but 153 ((36.1%) [31.7-40.8%]) did not know the NE dose reporting units at their institution. American and Asia/Middle East respondents reported starting NE infusions at half the dose reported by Europeans (respectively, 0.05 [0.03-0.05] and 0.05 [0.05-0.05] vs 0.1 [0.05-0.2] mcg/kg/min, (p < 0.001)) and considered adding second-line therapies at lower NE doses than European respondents in case of hypotensive septic shock (respectively, 0.15 [0.1-0.25] and 0.2 [0.1-0.3] vs 0.5 [0.3-1.00] mcg/kg/min (p < 0.0001).

conclusionThere were significant discrepancies in norepinephrine prescription and administration habits in PICUs worldwide. More than a third of pediatric intensivists did not know which norepinephrine formulation they used or what the dose reporting units referred to. Such discrepancies and lack of knowledge on the topic can compromise the standardization of norepinephrine dose reporting and the conduct of international multicenter studies in pediatric critical care. WHAT IS KNOWN: • Norepinephrine is recommended as a first line vasopressor in pediatric critical care, but multiple formulations of norepinephrine exist worldwide, and significant discrepancies in norepinephrine dose reporting were documented in adult publications, causing confusion in data interpretation. • This survey focuses on describing norepinephrine prescription habits in case of pediatric hypotensive shock and identifying discrepancies in the reporting of dosing units and conjugated salts of norepinephrine in pediatric intensive care units in America, Europe, Asia, Middle East, and Oceania. WHAT IS NEW: • This survey shows that a significant proportion of pediatric intensive care unit prescribers are unaware of the norepinephrine formulation they use and what the dosing units they prescribe refer to. • There is a significant twofold difference in terms of reported starting dose of norepinephrine in European vs. North American and Asian/Middle East prescribers. Clinicians should use norepinephrine base as their standard unit for norepinephrine dose reporting.