Management of arterial hypotension in critically Ill children: a narrative review and practical approach

Background Arterial hypotension in critically ill children is a frequent and high-risk clinical finding, yet universally accepted definitions, thresholds, and management strategies remain lacking. Blood pressure is an accessible but imperfect surrogate for circulatory adequacy, and uncertainty persists regarding when and how aggressively hypotension should be treated. Objective This narrative review aims to synthesize current evidence on the assessment and management of arterial hypotension in critically ill infants and children (beyond the neonatal period) and to translate these concepts into a structured, clinically applicable framework. Data sources and synthesis This publication synthesizes current international guidelines, recent clinical studies, and expert consensus on pediatric hemodynamic monitoring and shock management. Particular emphasis is placed on the interpretation of blood pressure in context, age-dependent mean arterial pressure (MAP) targets, and the integration of clinical examination, laboratory parameters, and point-of-care echocardiography. Results Arterial hypotension is typically a late sign of decompensated shock and is associated with increased mortality and adverse neurologic outcomes across multiple clinical scenarios, including septic shock, traumatic brain injury, and post-resuscitation care. MAP is the preferred parameter for assessment and therapeutic guidance. A pragmatic target of at least the 10th percentile for age appears reasonable in most critically ill children, balancing the risks of hypoperfusion and overtreatment. Early, repeated assessment using multimodal parameters—including cardiac point-of-care ultrasound—is essential. Initial management should prioritize rapid differentiation of shock etiology, judicious fluid resuscitation with balanced crystalloids, and early initiation of vasoactive therapy to avoid fluid overload. Emerging evidence supports norepinephrine as a first-line agent in distributive shock, with therapy tailored to underlying physiology. Conclusions This review provides a pragmatic synthesis of current knowledge and presents a structured, evidence-based framework to support the bedside assessment and management of arterial hypotension in critically ill children. The inclusion of schematic approaches is intended to enhance clinical applicability by organizing existing evidence into an accessible format, while not representing original or unpublished data.