European Journal of Cardiovascular Medicine

Septic shock is a significant cause of morbidity and mortality in children, especially in low- and middle-income settings with limited health systems. Pediatric septic shock is recognized by a systemic host response to infection that leads to circulatory, cellular, and metabolic alterations with a remarkably high risk of mortality. Despite advances in critical care, mortality remains extremely high, at least between 20% and 50% in many tertiary care settings (1–4).

Early recognition of clinical and laboratory risk factors that predict mortality in children with septic shock will aid in improving outcomes through timely interventions and resource allocations. Multiple studies have pointed to important, host-related factors such as altered mental status, hemodynamic status, organ dysfunction scores, and requirement of mechanical ventilation or vasoactive support as predictors of poor outcomes. Similarly, infection-related factors, including the etiological agent and presence of multi-organ dysfunction syndrome (MODS) appear to also be important factors in survival (5–8).

In India, pediatric septic shock remains a significant health problem, which varies in epidemiology and outcome because of heterogeneous health system access and prevalence of Infectious disease. Thus, there is a requirement for region-specific data to assist decision-making in a clinical context. Nonetheless, there are few prospective studies from Eastern India that assess the mortality risk factors among pediatric patients with septic shock (4,9).

In this regard, the current study focuses on analyzing the demographic, clinical, and laboratory predictors of mortality for children admitted to a tertiary care hospital in West Bengal with septic shock. This study aims to identify key risk factors related to death and add to the evidence-base for risk stratification, early intervention, and clinical management in resource-limited settings.

Study Design and Setting This was a planned observational study held for a period of one year at a tertiary care teaching hospital in West Bengal, India. The study was granted approval by the Institutional Ethics Committee and the parents or guardians of all participating children, provided informed consent. Study Population Children aged between one month to twelve years old, diagnosed clinically with septic shock and admitted in the pediatric medicine ward and pediatric intensive care unit (PICU) were enrolled. Septic shock was defined as per the Society of Critical Care Medicine Pediatric Sepsis Definition Task Force definitions which comprise infection with life-threatening cardiovascular dysfunction in children requiring vasoactive medications despite adequate fluid resuscitation. Inclusion and Exclusion Criteria Inclusion criteria included children meeting septic shock criteria between the age of one month to twelve years old, treated in the study duration. Exclusion criteria involved congenital anomalies, chronic illness interfering with immunological status, and for those who did not consent. Sampling Method: Simple random sampling Sample Size: 125 cases Daniel sample size formula: n = Z²pq/d² where n = sample size, Z = 1.96; Z statistic for a level of confidence, p = expected prevalence or proportion (60.46% as per the study by Kurade A et al. 94) q=1-p d = absolute precision. n= (1.96)2pq/d2 = (1.96)2×60.46×39.54/92 = 9183.68/92=113.38, which is taken as 114, which was rounded to 125 cases. Data Collection Demographic data (age, gender), clinical features including Glasgow Coma Scale (GCS) at the time of admission, etiological diagnosis as well as treatment variables (use of vasoactive medications, requirement for mechanical ventilation), laboratory investigations (complete blood counts, blood cultures, and markers of organ dysfunction, such as acute kidney injury (AKI)) were all documented. Organ dysfunction was evaluated based on validated scores: PRISM-III and PELOD-2 at admission and subsequently in the course of hospitalization. Mortality was considered as a primary outcome. Statistical Analysis The analysis of data was performed through SPSS software (version 26.0). Categorical variables were expressed as frequencies and percentile, while continuous variables were expressed as the mean or median as appropriate. The associations explored between categorical variables and mortality outcome used the chi-square test or Fischer’s exact test. A multivariate logistic regression model analyzed independent predictors of mortality. A p-value of less than 0.05 was considered statistically significant.

A total of 125 patients with clinically diagnosed septic shock were included, with 64.8% being less than five years of age. Female children accounted for 54% of the cohort and the male-to-female ratio was 1:1.12. The overall mortality was 34.4%. The most common etiologic diagnosis was pneumonia at 42.4%, followed by urinary tract infections and meningitis (16.8% each).

Tables 1-3 provide demographic; clinical and laboratory factors compared among survivors and non-survivors with multivariate logistic regression identifying independent mortality risk factors.

Table 1 shows the distribution of demographic and clinical risk factors among survivors and non-survivors. The variables that demonstrated no difference between groups were age under five years and male sex; however, strong associations were found in the remaining clinical variables in accordance with mortality. Specifically, a Glasgow Coma Scale (GCS) of ≤8 upon admission was observed more commonly in those who did not survive, attesting to the importance of neurologic status as a prognostic factor. Additionally, pneumonia as the primary etiology, use of vasoactive medications, mechanical ventilation and acute kidney injury (AKI) were also associated with increased mortality. These clinical factors indicate that organ dysfunction and interventions associated with critical care are strong predictors of poor outcomes.

Table 1: Demographic and Clinical Risk Factors Associated with Mortality

Legend: GCS: Glasgow Coma Scale; AKI: Acute Kidney Injury; p-value derived using Chi-square test.

Table 2 highlights the association between pertinent laboratory parameters and the fatalities for the study population. Non-survivors had significantly higher rates of thrombocytopenia and metabolic acidosis compared to survivors, signifying that derangements in hematologic and metabolic function are both valuable indicators of severity and poor outcomes. With the notable exception of the total leukocyte count (absence of leukopenia or leukocytosis) and blood culture positivity, laboratory parameters did not demonstrate significant differences between survivors and non-survivors (suggesting mortality to be less influenced by infection and influenced receptively by organ dysfunction).

Table 2: Laboratory Parameters and Mortality

Legend: p-value calculated using Chi-square test.

Table 3 displays the results of multivariate logistic regression, which identified independent mortality predictors. A GCS of ≤8 was established as the strongest predictor of mortality, increasing risk by more than 5 times. Other independent predictors of mortality included vasoactive medication, AKI, thrombocytopenia, and mechanical ventilation. In sum, organ dysfunction markers and multiorgan dysfunction with hemodynamic instability are critical determinants of mortality in critically ill patients.

Table 3: Multivariate Analysis of Predictors of Mortality

Legend: GCS: Glasgow Coma Scale; AKI: Acute Kidney Injury; CI: Confidence Interval; Odds Ratio (OR) with 95% CI presented.

This research investigated factors linked to mortality in pediatric septic shock at an eastern Indian tertiary care facility. The overall mortality of 34.4%, while worrisome, is consistent with the existing literature and aligns well with previously described ranges in resource-limited contexts between 20% and 40%. This finding continues to underscore the difficulty of managing septic shock in children, especially in resource-constrained locations (1,4,7).

We identified several independent predictors of mortality, including depressed neurologic status on admission (GCS ≤8), need for vasoactive support, need for mechanical ventilation, acute kidney injury (AKI), and thrombocytopenia. The relationship between low GCS and risk of mortality is consistent with previous studies that demonstrated encephalopathy was an indicator of organ dysfunction and poor prognosis in children. Vasoactive medication and mechanical ventilation both indicate hemodynamic instability and respiratory failure, which have been clearly demonstrated as strong mortality predictors in cohort studies of pediatric septic shock comparing survival in children with septic shock and susceptibility to severe disease (5,7,8,10).

Similarly, AKI was a significant risk factor which also demonstrates the multi-organ dysfunction burden in children who died from septic shock. This corroborates previous studies demonstrating the incidence or AKI commonly complicates pediatric sepsis and is implicated as a serious complication associated with mortality. Platelet count abnormalities, especially thrombocytopenia, were independently related to mortality, consistent with previous studies noting platelet dysfunction as a contributor to sepsis-related coagulopathy and organ failure (6,8,11–13).

In contrast, our findings revealed no difference in leukocyte count abnormalities (leucopenia/leukocytosis) and positive blood cultures between survivors and non-survivors; the literature contains mixed evidence, and such parameters can sometimes be unreliable predictors because of differences in the source of infection and host response (9,14).

That pneumonia was the most common etiology is consistent with current Indian and global pediatric septic shock epidemiology in which respiratory infection is a leading cause of sepsis. Understanding region-specific etiologies can facilitate effective identification, prevention, and treatment of sepsis (4,9,15).

This prospective study in a well-defined pediatric cohort contributes useful data to the current evidence base, especially from Eastern India where very limited evidence exists to our knowledge. However, it does have limitations, such as a single center and moderate sample size, and these limitations may hinder generalizability throughout India.

This study found that children with septic shock admitted to a tertiary hospital in Eastern India had a high mortality rate of 34.4%. The primary independent factors associated with mortality were depressed neurological level (GCS ≤8), use of vasoactive support, mechanical ventilation, acute kidney injury, and thrombocytopenia. These factors are an indication of the degree of multi-organ failure and hemodynamic compromise in fatal cases. Early detection and focused management of these high-risk characteristics are important to improving outcomes. Regional pattern of etiology, pneumonia as the leading cause, need focus on prevention and treatment to possibly improve mortality. This adds meaningful region-specific evidence to influence clinical decision-making and resource allocation in pediatric critical care.

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