Septic shock remains a critical cause of morbidity and mortality in the pediatric population worldwide. It represents the most severe spectrum of sepsis, characterized by circulatory, cellular, and metabolic dysfunction, often leading to multiple organ failure and death if not promptly recognized and managed [1]. Despite advancements in critical care, early recognition and timely intervention in pediatric septic shock continue to be challenging due to its rapidly evolving nature and variable presentation across different age groups.

Globally, sepsis contributes to an estimated 11 million deaths annually, with children under five accounting for a significant proportion, especially in low- and middle-income countries [2]. The burden is even more pronounced in India, where pediatric sepsis is frequently underdiagnosed, and standardized protocols for early recognition and escalation of care are inconsistently applied [3]. According to the World Health Organization, early identification of septic shock and risk stratification are essential to reduce pediatric sepsis-related deaths [4].

The pediatric population poses unique challenges in the diagnosis and prognostication of septic shock due to age-dependent physiological responses, difficulties in verbal communication of symptoms, and varying thresholds for decompensation [5]. Hence, the identification of predictive clinical and laboratory markers that correlate with adverse outcomes is vital in improving triage, therapeutic decisions, and prognosis. Several scoring systems and biomarkers — such as lactate levels, base deficit, Pediatric Logistic Organ Dysfunction (PELOD) score, and vasoactive-inotropic score (VIS) — have been explored in literature, but their applicability and accuracy vary across settings [6,7].

In the Indian context, studies investigating mortality predictors in pediatric septic shock are limited, and most existing evidence is extrapolated from adult populations or small retrospective cohorts. Furthermore, the etiology of sepsis, healthcare infrastructure, and response to treatment may vary significantly in Indian tertiary centers compared to high-income countries [8]. Therefore, prospective, context-specific research is essential to identify early indicators of poor prognosis and to guide clinical management in critically ill children.

This prospective observational study, conducted over 18 months (June 2023 to December 2024) at Tx Children’s Hospitals, Hyderabad, aims to analyze a cohort of 200 pediatric patients presenting with septic shock. The objective is to identify reliable clinical, hemodynamic, and biochemical predictors of in-hospital mortality, which can aid clinicians in risk stratification and early escalation of care. The findings are expected to contribute to the development of locally relevant protocols and improve outcomes in pediatric critical care settings.

This was a prospective observational study conducted in the Pediatric Intensive Care Unit (PICU) of Tx Children’s Hospitals, Hyderabad, over a period of 18 months from June 2023 to December 2024. The study aimed to identify clinical and laboratory predictors of mortality among children diagnosed with septic shock.

A total of 200 pediatric patients, aged between 1 month and 18 years, who presented with features of septic shock as per International Pediatric Sepsis Consensus Conference (IPSCC) definitions, were consecutively enrolled. Septic shock was defined as sepsis with cardiovascular dysfunction, requiring fluid resuscitation and/or vasoactive support. Patients were included if they fulfilled criteria for septic shock on admission or developed it during hospitalization. Children with congenital heart disease, terminal malignancies, or incomplete medical records were excluded from the study.

Following informed consent from parents or guardians, relevant clinical data were collected at admission, including age, sex, weight, immunization status, presenting symptoms, underlying comorbidities, and prior antibiotic use. Vital signs, Glasgow Coma Scale (GCS), capillary refill time, perfusion status, and need for mechanical ventilation or vasoactive drugs were documented.

Laboratory investigations performed at admission included complete blood count, serum lactate, CRP, procalcitonin, serum creatinine, electrolytes, blood culture, and arterial blood gas (ABG) analysis. Serial lactate and other relevant parameters were monitored during the course of treatment. Organ dysfunction was assessed using the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score. The Vasoactive Inotropic Score (VIS) was calculated to quantify cardiovascular support.

Patients were managed according to institutional PICU protocols and followed until hospital discharge or death. The primary outcome was in-hospital mortality. Secondary outcomes included duration of PICU stay, mechanical ventilation, and progression of organ dysfunction.

Data were entered into Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics were used for demographic and clinical characteristics. Univariate analysis was performed to identify potential predictors of mortality. Significant variables were then included in a multivariate logistic regression model to determine independent predictors of mortality. A p-value < 0.05 was considered statistically significant.

A total of 200 pediatric patients diagnosed with septic shock were enrolled during the 18-month study period. The overall in-hospital mortality rate was 34.5% (n = 69). The majority of patients (58%) were under 5 years of age, with a male predominance of 1.3:1. Fever (84%), altered sensorium (52%), and respiratory distress (45%) were the most common presenting symptoms.

Among clinical predictors, prolonged capillary refill time (>3 seconds), hypotension on admission, and need for mechanical ventilation were significantly associated with mortality. Laboratory parameters revealed that median serum lactate levels were significantly higher in non-survivors (4.9 mmol/L) compared to survivors (2.8 mmol/L), with lactate >4 mmol/L being strongly predictive of adverse outcome. Elevated CRP, procalcitonin, and leukocytosiswere also more frequent among non-survivors.

Scoring systems showed high discriminative power. The mean PELOD-2 score was significantly higher in the non-survivor group (15.2 ± 4.6) compared to survivors (8.4 ± 3.9). Similarly, VIS score >15 was strongly associated with poor outcome (p < 0.001). On multivariate logistic regression, the independent predictors of mortality were: serum lactate >4 mmol/L, PELOD-2 score >12, and need for mechanical ventilation at admission.

Table 1: Demographic and Clinical Profile of Study Participants (n = 200)

Table 2: Comparison of Key Parameters between Survivors and Non-Survivors

            *Statistically significant

Table 3: Detailed Analysis of Predictors of Mortality in Pediatric Septic Shock

*Significant at p < 0.05

This prospective study assessed mortality predictors among 200 pediatric patients with septic shock admitted to the PICU at Tx Children’s Hospitals, Hyderabad. The observed in-hospital mortality rate was 34.5%, which is comparable to findings from multiple Indian and international studies.

In a prospective study conducted by Sankar et al. (AIIMS, New Delhi, 2013), involving 200 children with septic shock, the reported mortality rate was 41%. Their study identified high lactate, need for mechanical ventilation, and fluid non-responsiveness as major predictors of death — findings that strongly align with our results where lactate >4 mmol/L (AOR 4.87), mechanical ventilation (AOR 3.68), and PELOD-2 >12 (AOR 5.21) were independent predictors [8].

Similarly, Sarthi et al. (2008, Delhi) conducted a prospective analysis on 130 children and reported a mortality rate of 32%. They observed that poor perfusion (CRT >3 sec) and hypotension on admission were strongly associated with mortality. In our study, CRT >3 sec (present in 62.3% of non-survivors) and admission hypotension (58%) were both significantly higher among non-survivors, supporting their role as early bedside indicators of poor outcome [9].

In an observational study by Taneja et al. (2021, PGIMER Chandigarh) involving 158 pediatric patients with septic shock, the authors reported a mortality rate of 36.1% and found PELOD-2 score >12, lactate >4 mmol/L, and VIS >15 to be independently associated with mortality. This mirrors our findings, wherein a PELOD-2 score >12 was observed in 72.5% of non-survivors, and VIS >15 in 73.9% of non-survivors, indicating consistency across settings [10].

Scott et al. (2016, Colorado, USA) evaluated lactate clearance and outcome in pediatric sepsis and reported that lactate >4 mmol/L at admission predicted ICU mortality, with non-survivors having significantly higher lactate levels (mean 5.1 mmol/L vs. 2.7 mmol/L). In our study, non-survivors had a mean lactate of 4.9 mmol/L, reinforcing lactate as a robust early prognostic marker [11].

Leteurtre et al. (France, 2013), in their validation of the PELOD-2 scoring system, reported that higher PELOD-2 scores correlated with multi-organ dysfunction and poor outcomes, which we also observed — with the mean PELOD-2 score in non-survivors (15.2) being significantly higher than in survivors (8.4) [12].

Regarding hemodynamic instability, Gaies et al. (2010, USA) demonstrated that higher VIS scores post cardiac surgery were independently predictive of mortality. Although their study population differed, our study found that VIS >15 was associated with nearly 4 times higher odds of death, supporting its utility in broader PICU settings [13].

Lastly, Weiss et al. (2020) in the Surviving Sepsis Campaign Pediatric Guidelines, emphasized the importance of early recognition of shock, lactate measurement, and scoring systems such as PELOD-2 to improve survival — a framework directly validated by our findings [14].

Collectively, these comparisons suggest that our study's key predictors — serum lactate >4 mmol/L, PELOD-2 score >12, need for mechanical ventilation, and high VIS — are consistent with the established global evidence. These variables are readily measurable in most tertiary settings and should be incorporated into early management algorithms and triage systems.

This prospective study identified key clinical and laboratory parameters that significantly predict mortality in pediatric patients with septic shock. The overall mortality rate of 34.5% underscores the severity of this condition and the urgent need for early risk stratification. Among the various factors analyzed, serum lactate >4 mmol/L, PELOD-2 score >12, requirement for mechanical ventilation, prolonged capillary refill time, and high vasoactive-inotropic scores emerged as strong independent predictors of poor outcomes.

These findings emphasize the importance of integrating simple, readily available bedside markers and scoring systems into the initial assessment and management of children presenting with septic shock. Early identification of high-risk patients allows timely escalation of care, optimization of organ support, and better resource allocation in intensive care settings. Future research should aim to validate these predictors in multicenter settings and explore the impact of targeted interventions based on early risk profiles to further reduce mortality in pediatric septic shock.

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