Epinephrine Versus Vasoactive Agents for Pediatric Septic Shock: A Systematic Review and Meta-Analysis of RCTs

The optimal first-line vasoactive agent for pediatric fluid-refractory septic shock remains uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials comparing epinephrine with dopamine or norepinephrine in pediatric septic shock. PubMed, Scopus, and Cochrane Library were searched from inception through October 2025. Seven RCTs involving 472 children were included, of whom 233 received epinephrine. Compared with dopamine, epinephrine showed no significant differences in all-cause mortality (RR 0.92; 95% CI 0.70–1.22), persistent shock at 1 hour (RR 1.77; 95% CI 0.67–4.68), or escalation to additional vasoactive therapy (RR 0.91; 95% CI 0.56–1.40). Similar findings were observed versus norepinephrine. In age-stratified analyses, children older than 1 month treated with epinephrine demonstrated higher rates of shock resolution at 1 hour, whereas no benefit was observed in neonates. Epinephrine and comparator vasoactive agents showed comparable overall outcomes in pediatric septic shock.