Maintaining an age-adapted mean arterial pressure (MAP) between 45–65 mmHg is a key goal in pediatric neurocritical care for ventilated children with brain injuries (trauma or post-tumor resection). While transcranial Doppler (TCD) remains a standard tool to guide cerebral perfusion, clinical practice often shifts toward individualized hemodynamic targets, which may vary depending on the on-call intensivist.

This prospective analysis highlights the deleterious systemic effects of excessive peripheral vasoconstriction induced by norepinephrine.

We reviewed 10 pediatric cases (mean age 7.5 ± 2.5 years) admitted to the PICU for severe brain injury. All received norepinephrine starting at 0.1 μg/kg/min, with subsequent up-titration up to 3 μg/kg/min by the attending intensivist based on cerebral perfusion pressure goals. The study focused on adverse effects observed at infusion rates between 1.5–2 μg/kg/min.

Among the 10 patients, 3 developed stage 3 oligo-anuric acute kidney injury (AKI) according to KDIGO criteria, requiring renal replacement therapy. Four patients, all undergoing posterior fossa tumor surgery, exhibited severe postoperative hyperglycemia (3.5–4 g/L) with ketonuria between 22 and 36 hours post-op, requiring continuous insulin infusion. By day 3, three patients developed hypertensive episodes (average 170/100 mmHg) with seizures and TCD evidence of intracerebral hyperemia. Brain CT scans revealed vasogenic edema compatible with posterior reversible encephalopathy syndrome (PRES). Management included discontinuation of norepinephrine, intravenous nifedipine, and enhanced anticonvulsant therapy with continuous infusion of barbiturates and benzodiazepines. Blood pressure stabilized by day 4 in all cases.

In pediatric neurocritical care, the escalation of norepinephrine doses to achieve cerebral perfusion targets can result in systemic vascular dysregulation and multiorgan complications. This study underscores the need for personalized, multimodal hemodynamic monitoring that integrates cerebral and cardiovascular risks. High-dose vasopressor therapy in children must be reassessed with caution, especially in the setting of posterior fossa pathology.