Refining mortality risk stratification in pediatric sepsis: the roles of PELOD-2, vasoactive-inotropic scores, and procalcitonin in a tertiary hospital in Eastern Indonesia

Arya Krisna Manggala; Dyah Kanya Wati; Ida Bagus Gede Suparyatha; I Nyoman Budi Hartawan

doi:10.4266/acc.002450

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Original Article Pediatrics Refining mortality risk stratification in pediatric sepsis: the roles of PELOD-2, vasoactive-inotropic scores, and procalcitonin in a tertiary hospital in Eastern Indonesia: Acute and Critical Care 2026;41(2):387-398.
DOI: https://doi.org/10.4266/acc.002450
Published online: April 17, 2026

Arya Krisna Manggala¹

, Dyah Kanya Wati²

, Ida Bagus Gede Suparyatha²

, I Nyoman Budi Hartawan²

¹Department of Child Health, Faculty of Medicine Udayana University, Ngoerah Hospital, Denpasar, Indonesia

²Pediatric Emergency and Intensive Care Division, Department of Child Health, Faculty of Medicine Udayana University, Ngoerah Hospital, Denpasar, Indonesia

Corresponding author: Dyah Kanya Wati Pediatric Emergency and Intensive Care Division, Department of Child Health, Faculty of Medicine Udayana University, Ngoerah Hospital, Denpasar 80113, Bali, Indonesia Tel: +62-857-3704-6003 Email: dyahkanyawati@unud.ac.id

• Received: July 10, 2025 • Revised: November 8, 2025 • Accepted: January 29, 2026

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
KEY MESSAGES
NOTES
REFERENCES

Abstract

Background
Sepsis is a leading cause of mortality and morbidity in children. While the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score is a common predictor of mortality, it does not account for the use of inotropic drugs or sepsis markers, which are addressed by the vasoactive-inotropic score (VIS) and measurements of procalcitonin levels. Combining these components enables faster and more accurate predictions of mortality risks. Therefore, this study aimed to develop a new stratification model of mortality risks by integrating PELOD-2, VIS, and procalcitonin among children with septic shock.
Methods
A single-center, three-year, retrospective cohort study was conducted in the pediatric intensive care unit of a tertiary hospital. Children aged 1 month to 18 years and diagnosed with septic shock between 2022 and 2024 received vasoactive and/or inotropic support within 24 hours of diagnosis. PELOD-2 scores and procalcitonin levels were recorded at diagnosis. The cutoff values for PELOD-2, VIS, and procalcitonin were determined using receiver operating characteristic curves. Multivariate analysis was used to generate a final equation and validated with the Hosmer-Lemeshow goodness-of-fit test.
Results
A total of 101 children were included, with a mortality rate of 78.2%. The optimal cutoff values were a PELOD-2 score ≥8 (sensitivity, 88.6%; specificity, 72.7%), a VIS score ≥11.5 (sensitivity, 78.5%; specificity, 72.7%), and a procalcitonin level ≥5 ng/ml (sensitivity, 74.7%; specificity, 68.2%). Multivariate analysis revealed significant associations with outcomes: PELOD-2 (adjusted odds ratio [aOR], 12.75; P<0.001), VIS (aOR, 4.686; P=0.02), and procalcitonin (aOR, 4.245; P=0.029). The new mortality risk prediction model achieved a range of 12.8% to 97.39% and exhibited excellent discriminator power (area under the curve, 0.911). The Hosmer–Lemeshow test confirmed good calibration.
Conclusions
The new scoring approach that refines stratification of mortality risks by incorporating PELOD-2, VIS, and procalcitonin is a more comprehensive predictor.
Key Words: child; multiple organ failure; procalcitonin; sepsis; septic shock; vasoactive agents

INTRODUCTION

Sepsis is a response to infection that results in organ dysfunction due to an abnormal immune response to infection [1]. In severe cases, children may progress to septic shock, which is characterized by cardiovascular dysfunction and hemodynamic instability, including severe hypotension for their age or the need for vasoactive medication [2]. In 2017, an estimated 25 million children worldwide were affected by sepsis, resulting in more than 3 million deaths [2]. Recent data from the Indonesian island of Bali showed that the mortality rate for septic shock reached 47.1% [3]. Sepsis remains a leading cause of serious illness and mortality in hospitalized children, leading to lost years of life, increased morbidity, and missed developmental opportunities [4].

Various scoring systems have been developed to predict mortality outcomes in children with sepsis. The Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score, an updated version of the original PELOD score enhanced by Leteurtre et al. [5], is widely used to predict mortality and is included in Indonesia’s national guidelines [1]. However, in resource-limited settings, a lack of certain components, such as lactate measurements, may compromise the accuracy and reliability of the PELOD-2 score [6]. Application of the PELOD-2 score is often modified in accordance with specific clinical settings and the availability of local resources [7].

The vasoactive-inotropic score (VIS), initially introduced by Gaies et al. [8], was designed to quantify the cardiovascular support provided by vasoactive and inotropic agents following cardiac surgery in infants. It incorporates the use of dopamine, dobutamine, epinephrine, milrinone, vasopressin, and norepinephrine. It has been shown to correlate with worse short-term outcomes in post-surgery infants. McIntosh et al. [9] and Haque et al. [10] validated the usefulness of the VIS in pediatric cases of septic shock, finding that higher scores were strongly associated with increased mortality. Both studies also found that the VIS was a reliable marker of cardiovascular support and a valuable adjunct to existing pediatric severity scores [9].

As a well-established biomarker in sepsis, procalcitonin can distinguish bacterial from viral infections, and is reflective of disease severity. Higher procalcitonin levels have consistently been associated with increased mortality in pediatric sepsis [11-13].

Numerous studies have evaluated the individual predictive abilities of the PELOD-2 score VIS, and procalcitonin levels in determining outcomes for children with septic shock. However, to date, no study has examined the combined prognostic value of these measures. The PELOD-2 score does not account for inotropic support, whereas the VIS can offer additional insight to improve predictions of mortality risk in children with septic shock. Furthermore, emerging biomarkers such as procalcitonin could potentially enhance the accuracy of prognostic scoring systems. By combining these components, mortality could be better predicted, which would enhance treatment strategies and provide parents with earlier information regarding the prognosis.

MATERIALS AND METHODS

Ethics Statement

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and received approval from the Ethics Committee of Ngoerah Hospital (No. 1102/UN14.2.2.VII.14/LT/2025). Due to the retrospective nature of the study design, the requirement for informed consent from patients or parents was waived.

Study Design

This retrospective cohort study was conducted in the pediatric intensive care unit (PICU) of a tertiary referral hospital in Eastern Indonesia. It aimed to identify predictors of sepsis-related mortality among children by evaluating the combined utility of the PELOD-2 score, VIS, and procalcitonin levels in enhancing mortality risk stratification.

Study Population

The study enrolled children aged 1 month to 18 years who were diagnosed with septic shock based on clinical assessments and supporting investigations, in accordance with the hospital’s clinical practice guidelines and/or the 2021 Indonesian national sepsis guidelines. Diagnoses were confirmed by a pediatric intensive care consultant. All included patients received vasoactive and/or inotropic support within 24 hours following the diagnosis of septic shock. Exclusion criteria included patients who had received vasoactive and/or inotropic agents prior to PICU admission—either at referring facilities or discontinued before arrival—as well as those with incomplete data at the time of diagnosis of septic shock in the PICU. Incomplete data referred specifically to missing procalcitonin measurements, absent PELOD-2 components (except lactate), or undocumented vasoactive/inotropic dosing information. Patients with incomplete data were excluded from the analysis.

Sample Size

The sample size was computed based on tests of hypotheses for the two proportions using a two-tailed approach, a 5% significance level, a 20% margin of error, and a 95% CI to control for type I error. The sample was selected using consecutive sampling, including all patients who met the inclusion criteria during the study period. The minimum required sample size was determined to be 94, based on a previous study reporting a 72% mortality rate among patients by lower VISs (i.e., devoid of the exposure) [13].

Data Collection and Operational Variables

We collected data on demographic characteristics including age, sex, nutritional status, referral status, the primary organ system involved at admission, surgical interventions during hospitalization, blood culture results, number of vasoactive/inotropic medications administered, use of mechanical ventilation, length of stay in the PICU, and patient outcomes. Independent variables such as the PELOD-2 score (excluding lactate), the VIS within 24 hours, and procalcitonin levels at the time of septic shock diagnosis were analyzed to establish cutoff values for predicting patient outcomes (survival versus non-survival). The data were collected from electronic medical records via the Hospital Information System from October 2022 to December 2024. These secondary data were subsequently extracted and organized utilizing Microsoft Excel.

Septic shock is a severe manifestation of sepsis marked by cardiovascular dysfunction, which is associated by greater mortality rates. A diagnosis of septic shock is established clinically or supported by diagnostic tests in accordance with local and national clinical guidelines [1], and confirmed by an intensive care pediatricians, as documented in electronic medical records. Age refers to the patient’s chronological age at the time of admission, using their date of birth and expressed in complete years. Sex classification was based on phenotypic characteristics. Nutritional status was assessed by measuring patient weight and height or length during the PICU stay. For subjects under 5 years of age, malnutrition was defined as undernutrition or being at risk of overweight and obesity, based on weight-for-height or weight-for-length measurements. For subjects aged 5 years and older, malnutrition was classified according to undernutrition, risk of overweight, overweight, or obesity, using body mass index–for–age criteria in accordance with the 2020 World Health Organization child anthropometry standards guidelines. The VIS was computed as the weighted sum of all inotropic and vasoconstrictive agents administered within 24 hours following a diagnosis of septic shock in the PICU. The formula used was: VIS=dopamine (µg/kg/min)+dobutamine (µg/kg/min)+100×norepinephrine (µg/kg/min)+100×epinephrine (µg/kg/min)+10×milrinone (µg/kg/min)+10,000×vasopressin (µg/kg/min) [14]. The PELOD-2 is a clinical tool designed to evaluate the extent of multi-organ dysfunction, encompassing neurological, cardiovascular, renal, respiratory, and hematological systems. The national guideline defines a PELOD-2 score >10 as indicative of organ dysfunction. However, because lactate measurements are not routinely available, we established a new cutoff value. Procalcitonin levels were determined by blood chemistry analyses at the time septic shock was diagnosed. Referral status indicates whether the patient arrived at the emergency room (ER) via transfer from another hospital or presented to the ER independently. Surgical history refers to any surgical procedures performed on the patient related to their underlying condition during the admission period. Mechanical ventilation denotes the use of an invasive device to support or replace spontaneous breathing, enhance gas exchange, and decrease respiratory effort; it employs modes such as pressure-controlled or volume-controlled ventilation. Outcome refers to the patient’s final clinical status at the end of the hospital stay. PICU length of was the total duration from admission to discharge within a single hospitalization, irrespective of the outcome. The primary organ system involved at admission was the main physiological system corresponding to the patient’s chief complaint that warranted PICU admission. Blood culture results were the findings of a laboratory test conducted on a blood sample to identify the presence of microorganisms responsible for systemic infection.

Statistical Analysis

Demographic characteristics were summarized using the mean (with standard deviations) or median (with minimum-to-maximum ranges), depending on the distribution as assessed by the Kolmogorov-Smirnov normality test. Categorical variables were presented as frequencies (n) and percentages (%). Cutoff values for the PELOD-2 score, VIS, and procalcitonin levels were determined through receiver operating characteristic (ROC) curve analysis, with the area under the curve (AUC) used to evaluate predictive performance. Optimal cutoff values were identified using the Youden Index (J=sensitivity+specificity–1). When a statistically significant of AUC (P<0.05) was observed, sensitivity and specificity were calculated for the corresponding threshold. All AUC values were interpreted as follows: 0 indicated no discriminatory ability; 0.7–0.8, moderate or acceptable discrimination; 0.8–0.9, excellent discrimination; and 0.9–1.0, outstanding or near-perfect discrimination.

Cross-tabulation was performed to assess the associations between independent variables, selected demographic factors, and the dependent variable (outcome). Bivariate analysis results were reported by P-values, odds ratios (ORs), and 95% CIs, applying either a chi-square test or Fisher’s exact test, depending on data distribution. Variables that were statistically significant (P<0.05) in the bivariate analysis were analyzed further using multivariate analysis by backward logistic regression to identify the factors most strongly associated with the outcomes. The final multivariate model included unstandardized coefficients or adjusted ORs (aORs), P-values, and 95% CIs. Based on this model, a scoring equation was developed and its goodness of fit was evaluated using the Hosmer-Lemeshow test. The model’s predictive performance was assessed by an ROC curve analysis. All statistical analyses were conducted using IBM SPSS version 26.0 (IBM Corp.).

RESULTS

During the study period, 889 children were admitted to the PICU of a tertiary hospital in Eastern Indonesia. Among them, 107 were diagnosed with septic shock and required vasoactive or inotropic therapy. After applying the exclusion criteria, 101 children aged 1 month to 18 years were included in the analysis (Figure 1). Excluded patients were those receiving vasoactive or inotropic agents before PICU admission, those whose therapy was discontinued before admission, and those with incomplete data for procalcitonin, PELOD-2 score, or vasoactive-inotropic dosing.

More than half (52.5%) of the patients were male, under five years old (57.4%), malnourished (59.4%), or referred from other hospitals (51.5%). Respiratory involvement was the most frequent underlying system (22.8%), and 91.1% required mechanical ventilation. Only 7.9% of patients had positive blood cultures. The median PELOD-2 score, VIS, and procalcitonin level were 10 (range, 0–19), 20 (range, 2–200), and 11.78 ng/ml (range, 0.04–2,311), respectively. The overall mortality rate was 78.2%.

Non-survivors had significantly a higher PELOD-2 score, VIS, and procalcitonin levels, as well as longer PICU stays compared with survivors (Table 1). ROC analysis identified optimal cutoff values of 8 for PELOD-2 score, 11.5 for the VIS, and 5 ng/ml for procalcitonin, with AUCs of 0.89, 0.82, and 0.76, respectively, indicating excellent discrimination for the PELOD-2 and VIS and moderate discrimination for procalcitonin (Figure 2).

Bivariate analysis revealed several significant risk factors for mortality in children with septic shock, including the need for invasive mechanical ventilation (OR, 9.50; 95% CI, 2.14–42.02; P=0.003), a PELOD-2 score ≥8 (OR, 20.74; 95% CI, 6.64–66.63; P<0.001), a VIS ≥11.5 (OR, 9.73; 95% CI, 3.30–28.67; P<0.001), and a procalcitonin level ≥5 ng/ml (OR, 6.32; 95% CI, 2.26–17.72; P<0.001) (Table 2).

Multivariate analysis using the backward logistic regression method indicated that only PELOD-2 (aOR, 12.822; 95% CI, 3.481–47.238; P<0.001), VIS (aOR, 4.686; 95% CI, 1.280–17.158; P=0.02), and procalcitonin (aOR, 4.245; 95% CI, 1.158–15.566; P=0.029) were significantly associated with outcomes in children with septic shock (Table 3). The final multivariate model yielded the following equation: y=−1.923+2.551 (PELOD-2)+1.545 (VIS)+1.446 (procalcitonin). The Hosmer–Lemeshow goodness-of-fit test determined good model calibration (χ²=2.24, P=0.69). According to the equation, the highest probability of mortality in children with septic shock occurred among those with a PELOD-2 score ≥8, a VIS ≥11.5, and procalcitonin levels ≥5 ng/ml, corresponding to a mortality probability of 97.39% (Figure 3). The combined use of the PELOD-2 score, VIS, and procalcitonin, as assessed by the new ROC curve, yielded an AUC of 0.911 (95% CI, 0.85–0.97; P<0.001), indicating outstanding discriminative ability (Figure 4).

DISCUSSION

This study found that integrating the PELOD-2 score, VIS, and procalcitonin levels markedly improved mortality prediction in pediatric septic shock compared with using any of these parameters alone. Each of these indicators reflected distinct aspect of the sepsis pathophysiology: PELOD-2 quantified organ dysfunction [1], VIS reflected cardiovascular support intensity [9], and procalcitonin levels represented systemic inflammatory activity [11,15]. Their combined use therefore offers a more comprehensive assessment of illness severity. To our knowledge, this is among the first studies to evaluate the integrated prognostic value of these three parameters in a resource-limited, pediatric intensive care setting. These findings underscore the potential clinical utility of this combined approach in improving early risk stratification and guiding timely management decisions for children with septic shock.

The majority of subjects were male and younger than 5 years old. This finding aligns with a study conducted in India that reported that children aged less than 5 years (with a median age of 3 years) and males (58.3%) were predominantly affected by septic shock [16]. Males may have a higher susceptibility to infections, as females typically exhibit a stronger CD4+ T-cell response [17].

Most of the children in this study were either undernourished or over-nourished, with 59.4% falling into these categories. A study conducted in Iran found that 31.5% of pediatric sepsis cases were undernourished [18], while in the United States, 40% of sepsis cases involved over-nourishment [19]. Both undernutrition and overnutrition can negatively affect immune function in sepsis. Undernutrition leads to metabolic disturbances, causing muscle breakdown (hyper-catabolism) and the release of cytokines and chemokines [18]. Obesity, by comparison contributes to chronic inflammation, weakens immune functions, increases vulnerability to infections, and alters the body’s immune response [19,20].

Most of the patients in this study required mechanical ventilation (91.1%), and bivariate analysis showed a significant association. A study in Indonesia found that 79.4% of children with septic shock required mechanical ventilation, with non-survivors experiencing a higher incidence, making it a significant risk factor for mortality in children (OR, 16.38; 95% CI, 2.69–99.66; P=0.002) [21]. A retrospective study in China [22] also found that mechanical ventilation lasting ≥96 h was strongly correlated with a higher pediatric sequential organ-failure assessment score, indicating an increased risk of septic shock as the duration of mechanical ventilation increased. The study also showed that prolonged mechanical ventilation heightened the risk of ventilator-associated pneumonia and increased antibiotic use, and extended the length of hospitalization [22].

The mortality rate of septic shock in our study was 78.2%, which is higher than the 47.1% reported by a 2019 study at our center [3]. This increased mortality rate may be attributable to the fact that the subjects in our study were limited to those receiving vasoactive-inotropic medications, indicating greater illness severity. In addition, although referral status was not statistically associated with mortality, a high proportion (78.8%) of non-survivors were referred from other hospitals, which may have contributed to delays in hemodynamic stabilization and disease progression. Moreover, due to the high number of referrals and limited PICU bed availability at our center, some patients may have experienced delays in initial management at the referring hospitals, potentially contributing to the progression of sepsis. Resource limitations in referring facilities, including restricted access to advanced hemodynamic support and PICU-level monitoring, may have also affected treatment responsiveness [23]. While our results included a higher mortality rate compared with those of the earlier study at our center, they are similar to those reported by a study conducted at a tertiary center in Jakarta, in which the mortality rate of 78.6% was primarily due to underlying disease [13]. This confirms that mortality rates vary across settings and populations, and emphasizes how patient-referral patterns, treatment delays, and healthcare infrastructure can influence outcomes in cases of pediatric septic shock.

The median PELOD-2 score in this study was 10 (range, 0–19), with an optimal cutoff value of 8. This cutoff demonstrated a sensitivity of 88.6%, a specificity of 72.7%, and an AUC of 0.89, indicating a 12.822-fold increased risk of predicted mortality in cases of pediatric sepsis. The PELOD-2 score is widely used to predict multiorgan dysfunction and is a standard in our national guidelines. However, due to the lack of lactate testing at our center, we used a modified PELOD-2 score, with an optimal cutoff point of 8. This modification addresses limitations arising from unavailable laboratory parameters while maintaining prognostic utility.

Comparatively, a study by Melda [6] demonstrated that the modified PELOD-2 score (excluding lactate) had a median score of 8 (range, 6–12) among non-survivors in critically ill children. A cutoff value of ≥6.5 yielded a sensitivity of 70.6% and a specificity of 77.4%, resulting in an 8.23-fold increased risk of mortality [6]. Similarly, a study in Indonesia found that PELOD-2 scores with or without lactate testing produced comparable sensitivity and specificity, with a strong positive predictive value and similarly positive likelihood ratios; the AUC difference was only 0.1%, indicating minimal impact on predicting severe organ dysfunction [7]. In Vietnam [24], a modified PELOD-2 score ≥9 achieved 81.1% sensitivity and 89.6% specificity for predictions of mortality in children with multiple organ dysfunction, a result explained by regression analyses showing that differences in lactate levels were not statistically significant. Furthermore, this score produced results superior to those of the Pediatric Index of Mortality 3 [24]. Taken together, these findings support the reliability of the modified PELOD-2 score for predicting mortality, particularly where lactate testing is limited, and provide a strong basis for combining the PELOD-2 with VIS and procalcitonin in our predictive model.

The VIS in this study had a median of 20 (range, 2–200), with a cutoff value of ≥11.5, providing a sensitivity of 78.5%, a specificity of 72.7%, and an AUC of 0.82, for a 4.686-fold increased risk of sepsis mortality. These results were similar to a study by Pudjiadi [13] in which an optimal VIS cutoff value of ≥11 yielded a sensitivity of 78.8% and a specificity of 72.2%, with an AUC of 0.757, achieving a lower discriminatory power compared with our study. Patients with a high VIS reportedly experience ongoing cardiovascular dysfunction [9]. A higher score reflects more severe coronary blood flow impairment, reduced oxygen levels, myocardial hypokinesis, and ventricular dilation, leading to myocardial dysfunction and the release of troponin from cardiac myocytes [9]. Studies have also found that a higher VIS correlates with elevated troponin I and T levels, further emphasizing the increased risk of poor outcomes [25].

Procalcitonin is a valuable marker in sepsis that is released by parenchymal cells in response to bacterial toxins. It elevates inflammatory cytokine levels, leads to deterioration of neutrophil, lymphocyte, and macrophage function, triggers inflammatory cascades, and promotes vasodilation and cardiovascular instability [26,27]. These effects play a critical role in the progression of sepsis and are closely linked to increased morbidity and mortality [26,27]. Measurements of procalcitonin have also been shown to outperform C-reactive protein and leukocyte counts in diagnostic accuracy [15]. In this study, a procalcitonin level ≥5 ng/ml provided a sensitivity of 74.7%, a specificity of 68.2%, and an AUC of 0.76, corresponding to a 4.245-fold greater risk of mortality. A study by Lubis et al. [28] reported that combining the PELOD-2 score with procalcitonin levels improved mortality prediction in pediatric sepsis, yielding an AUC of 0.95 compared with 0.75 for PELOD-2 scores alone and 0.80 when combined with C-reactive protein levels. In our study, we enhanced this approach by incorporating the VIS into the model. The combination of PELOD-2, VIS, and procalcitonin achieved an AUC of 0.911 (95% CI, 0.85–0.97), demonstrating excellent discriminative ability and producing a predicted mortality probability of up to 97.39%. This finding suggests that including a hemodynamic parameter such as the VIS may provide additional prognostic value beyond clinical and biochemical markers alone. Nevertheless, because our model was developed from a single-center retrospective cohort; external validation in larger, multicenter prospective studies is strongly recommended to confirm its generalizability and clinical applicability. In practice, clinicians could use these cutoffs to rapidly identify high-risk children and prioritize monitoring or escalate therapy accordingly.

This study is the first to enhance the prediction of septic shock likelihood by integrating three sepsis-assessment tools. Multivariate analysis revealed that the greatest risk of mortality in children with septic shock is observed when PELOD-2 scores are ≥8, VIS scores are ≥11.5, and procalcitonin levels are ≥5 ng/ml, achieving a 97.39% probability of death by excellent discriminatory power.

This study has several limitations. First, it was conducted at a single tertiary care center with a retrospective design, which may limit the generalizability of the findings and introduces potential information bias due to the reliance on medical record data. Second, the sample size was relatively small, which may reduce the statistical power of some subgroup analyses. Third, certain laboratory variables, such as serum lactate, were not included due to inconsistent data availability, which may have influenced the performance of PELOD-2 scoring. Furthermore, external validation by larger, multicenter, prospective studies is required to confirm the model’s predictive accuracy and applicability.

This study found the combined use of PELOD-2 scores, the VIS, and procalcitonin levels is a promising tool for predicting mortality risk in children with septic shock. The cutoff values established in this study (PELOD-2 >8, VIS >11.5, and procalcitonin >5 ng/ml) correspond to progressively higher mortality probabilities, reaching 97.39% when all thresholds are exceeded. These parameters could be readily integrated into a simple bedside risk calculator or score sheet to support rapid and objective clinical decision-making in a PICU. Additionally, this information can be communicated to patients’ families to enhance their understanding of the prognosis.

KEY MESSAGES

▪ The mortality rate of pediatric septic shock at our tertiary referral hospital was 78.2%.

▪ Pediatric Logistic Organ Dysfunction-2 ≥8, vasoactive-inotropic score ≥11.5, procalcitonin ≥5 ng/ml were identified as significant predictors of mortality.

▪ A new predictive equation combining these factors showed excellent discriminative ability (area under the curve, 0.911), suggesting its potential use as a clinical tool for early mortality risk stratification.

NOTES

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: AKM, DKW, IBGS, INBH. Data curation: AKM, DKW. Statistical analysis: AKM, DKW, INBH. Methodology: AKM, DKW, IBGS, INBH. Writing – original draft: AKM, DKW. Writing – review and editing: DKW, IBGS, INBH. All authors read and agreed to the published version of the manuscript.

Figure 1.

Study flowchart and data collection. PICU: pediatric intensive care unit.

Figure 2.

The optimal cutoff value for the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score was 8, with a sensitivity of 88.6%, a specificity of 72.7%, a positive predictive value (PPV) of 92.1%, a negative predictive value (NPV) of 64.0%, an accuracy of 85.2%, an area under the curve (AUC) of 0.89 (95% CI, 0.83–0.96; P<0.001), and a Youden index of 0.65 (green line). The optimal cutoff value for the vasoactive-inotropic score (VIS) was 11.5, with a sensitivity of 78.5%, a specificity of 72.7%, a PPV of 91.2%, an NPV of 48.5%, an accuracy of 77.2%, an AUC of 0.82 (95% CI, 0.74–0.90; P<0.001), and a Youden index of 0.49 (blue line). The optimal cutoff value for procalcitonin levels was 5 ng/ml, with a sensitivity of 74.7%, a specificity of 68.2%, a PPV of 89.4%, an NPV of 42.9%, an accuracy of 73.3%, an AUC of 0.76 (95% CI, 0.65–0.87; P<0.001), and a Youden index of 0.42 (red line). ROC: receiver operating characteristic.

Figure 3.

The percentage probability of mortality was determined using a scoring classification based on three parameters (Pediatric Logistic Organ Dysfunction-2 [PELOD-2], vasoactive-inotropic score [VIS], and procalcitonin). A score of 1 was assigned for each of a PELOD-2 score ≥8, a VIS ≥11.5, and a procalcitonin level ≥5 ng/ml. A higher total score reflects an increased probability of mortality in pediatric patients with septic shock.

Figure 4.

Combination of Pediatric Logistic Organ Dysfunction-2, vasoactive-inotropic score, and procalcitonin showed am area under the curve of 0.911 (95% CI, 0.85–0.97; P<0.001). ROC: receiver operating characteristic.

Table 1.

Demographic characteristics of the subjects

Variable	Total (n=101)	Non-survivor (n=79)	Survivor (n=22)
Age (yr)	3 (0–17)	4 (0–17)	1 (0–17)
Sex
Male	53 (52.5)	42 (79.2)	11 (20.8)
Female	48 (47.5)	37 (77.1)	11 (22.9)
Nutritional status
Malnutrition	60 (59.4)	49 (81.7)	11 (18.3)
Well-nourished	41 (40.6)	30 (73.2)	11 (26.8)
Referral status
Referred	52 (51.5)	41 (78.8)	11 (21.2)
Not referred	49 (48.5)	38 (77.6)	11 (22.4)
Primary organ system involved in the presenting diagnosis at admission
Respiratory	23 (22.8)	16 (69.6)	7 (30.4)
Neurology	15 (14.9)	14 (93.3)	1 (6.7)
Gastrohepatology	3 (3.0)	2 (66.7)	1 (33.3)
Cardiovascular	21 (20.8)	15 (71.4)	6 (28.6)
Hematology-oncology	10 (9.9)	10 (100.0)	0
Infection and tropical disease	2 (2.0)	2 (100.0)	0
Nutrition	1 (1.0)	1 (100.0)	0
Endocrinology	2 (2.0)	0	2 (100.0)
Immunology	6 (5.9)	6 (100.0)	0
Nephrology	10 (9.9)	7 (70.0)	3 (30.0)
Trauma	8 (7.9)	6 (75.0)	2 (25.0)
History of surgery
Yes	30 (29.7)	23 (76.7)	7 (23.3)
No	71 (70.3)	56 (78.9)	15 (21.1)
Blood culture result
Positive	8 (7.9)	8 (100)	0
Acinetobacter baumannii	1 (1)
Pseudomonas aeruginosa	2 (2)
Staphylococcus aureus	1 (1)
Staphylococcus capitis	1 (1)
Stenotrophomonas maltophilia	1 (1)
Streptococcus intermedius	1 (1)
Negative	93 (92.1)	71 (76.3)	22 (21.8)
Vasoactive-inotropic medication
Dopamine	3 (3)	2 (66.7)	1 (23.3)
Dobutamine	31 (30.7)	25 (80.0)	6 (20.0)
Epinephrine	79 (78.2)	64 (81.0)	15 (19.0)
Milrinone	7 (6.9)	7 (100.0)	0
Vasopressin	0	0	0
Norepinephrine	32 (31.7)	29 (90.0)	3 (10)
Number of vasoactive/inotropic
1	57 (56.4)	38 (66.7)	19 (33.3)
2	38 (37.6)	35 (92.1)	3 (7.9)
3	6 (5.9)	6 (100.0)	0
Mechanical ventilation
Yes	92 (91.1)	76 (82.6)	16 (17.4)
No	9 (8.9)	3 (33.6)	6 (66.7)
PELOD-2 score	10 (0–19)	12 (4–19)	7 (0–12)
VIS	20 (2–200)	25 (2–200)	10 (3–20)
Procalcitonin (ng/ml)	11.78 (0.04–2,311)	23.34 (0.13–2,311)	2.67 (0.04–343)
PICU length of stay (day)	6 (0–72)	5 (0–42)	10.5 (5–72)

Values are presented as median (range) or number (%).

PELOD-2: Pediatric Logistic Organ Dysfunction-2; VIS: vasoactive-inotropic score; PICU: pediatric intensive care unit.

Table 2.

Risk factors of mortality among pediatrics with septic shock on bivariate analysis

Variable	Outcome		P-value^a)	OR^b)	95% CI
Variable	Non-survivor (n=79)	Survivor (n=22)	P-value^a)	OR^b)	95% CI
Age (yr)				-	-
<5	43 (74.1)	15 (25.9)	0.249
≥5	36 (83.7)	7 (16.3)
Sex				-	-
Boy	42 (79.2)	11 (20.8)	0.793
Girl	37 (77.1)	11 (22.9)
Nutritional status				-	-
Malnourished	49 (80.4)	11 (18.3)	0.310
Well-nourished	30 (73.2)	11 (26.8)
Referral				-	-
Referral	41 (78.8)	11 (21.2)	0.875
Not referral	38 (77.6)	11 (22.4)
History of surgery				-	-
Yes	23 (76.7)	7 (23.3)	0.806
No	56 (78.9)	15 (21.1)
Required mechanical ventilation			0.003	9.50	2.14–42.02
Yes	76 (82.6)	16 (17.4)
No	3 (33.3)	6 (66.7)
PELOD-2			<0.001	20.74	6.46–66.63
≥8	70 (92.1)	6 (7.9)
< 8	9 (36.0)	16 (64.0)
VIS			<0.001	9.73	3.30–28.67
≥11.5	62 (91.2)	6 (8.8)
< 11.5	17 (51.5)	16 (48.5)
Procalcitonin (ng/ml)			<0.001	6.32	2.26–17.72
≥5	59 (89.4)	7 (10.6)
<5	20 (57.1)	15 (42.9)

Values are presented as number (%).

OR: odd ratio; PELOD-2: Pediatric Logistic Organ Dysfunction-2; VIS: vasoactive-inotropic score.

^a)P-value is based on bivariate analysis using chi-square test or fisher-exact test;

^b)Possible risk factors with P<0.05 were included in multivariate analysis model using logistic regression.

Table 3.

The final multivariate analysis using backward likelihood ratio methods

Variables in the equation		B	SE	Wald	dF	Sig.	Exp (B)	95% CI for Exp (B)
Step 1	PELOD-2	2.623	0.765	11.774	1	0.001	13.783	3.080–61.678
	Procalcitonin	1.442	0.663	4.733	1	0.030	4.231	1.154–15.516
	MV	–0.197	1.014	0.038	1	0.846	0.821	0.113–5.990
	VIS	1.569	0.675	5.407	1	0.020	4.800	1.280–18.007
	Constant	–1.809	0.877	4.252	1	0.039	0.164	-
Step 2	PELOD-2	2.551	0.665	14.703	1	0.000	12.822	3.481–47.238
	VIS	1.545	0.662	5.441	1	0.020	4.686	1.280–17.158
	Procalcitonin	1.446	0.663	4.756	1	0.029	4.245	1.158–15.566
	Constant	–1.923	0.660	8.486	1	0.004	0.146	-

Equation of the scoring: y=–1.923+2.551 (PELOD-2)+1.545 (VIS)+1.446 (procalcitonin).

B: unstandardized regression coefficient; SE: standard error; df: degrees of freedom; Sig: significance; Exp(B): exponentiated B; PELOD-2: Pediatric Logistic Organ Dysfunction-2; MV: mechanical ventilation; VIS: vasoactive-inotropic score.

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Refining mortality risk stratification in pediatric sepsis: the roles of PELOD-2, vasoactive-inotropic scores, and procalcitonin in a tertiary hospital in Eastern Indonesia

Acute Crit Care. 2026;41(2):387-398. Published online April 17, 2026

DOI: https://doi.org/10.4266/acc.002450

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Figure

Refining mortality risk stratification in pediatric sepsis: the roles of PELOD-2, vasoactive-inotropic scores, and procalcitonin in a tertiary hospital in Eastern Indonesia

Figure 1. Study flowchart and data collection. PICU: pediatric intensive care unit.

Figure 2. The optimal cutoff value for the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score was 8, with a sensitivity of 88.6%, a specificity of 72.7%, a positive predictive value (PPV) of 92.1%, a negative predictive value (NPV) of 64.0%, an accuracy of 85.2%, an area under the curve (AUC) of 0.89 (95% CI, 0.83–0.96; P<0.001), and a Youden index of 0.65 (green line). The optimal cutoff value for the vasoactive-inotropic score (VIS) was 11.5, with a sensitivity of 78.5%, a specificity of 72.7%, a PPV of 91.2%, an NPV of 48.5%, an accuracy of 77.2%, an AUC of 0.82 (95% CI, 0.74–0.90; P<0.001), and a Youden index of 0.49 (blue line). The optimal cutoff value for procalcitonin levels was 5 ng/ml, with a sensitivity of 74.7%, a specificity of 68.2%, a PPV of 89.4%, an NPV of 42.9%, an accuracy of 73.3%, an AUC of 0.76 (95% CI, 0.65–0.87; P<0.001), and a Youden index of 0.42 (red line). ROC: receiver operating characteristic.

Figure 3. The percentage probability of mortality was determined using a scoring classification based on three parameters (Pediatric Logistic Organ Dysfunction-2 [PELOD-2], vasoactive-inotropic score [VIS], and procalcitonin). A score of 1 was assigned for each of a PELOD-2 score ≥8, a VIS ≥11.5, and a procalcitonin level ≥5 ng/ml. A higher total score reflects an increased probability of mortality in pediatric patients with septic shock.

Figure 4. Combination of Pediatric Logistic Organ Dysfunction-2, vasoactive-inotropic score, and procalcitonin showed am area under the curve of 0.911 (95% CI, 0.85–0.97; P<0.001). ROC: receiver operating characteristic.

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Refining mortality risk stratification in pediatric sepsis: the roles of PELOD-2, vasoactive-inotropic scores, and procalcitonin in a tertiary hospital in Eastern Indonesia

Variable	Total (n=101)	Non-survivor (n=79)	Survivor (n=22)
Age (yr)	3 (0–17)	4 (0–17)	1 (0–17)
Sex
Male	53 (52.5)	42 (79.2)	11 (20.8)
Female	48 (47.5)	37 (77.1)	11 (22.9)
Nutritional status
Malnutrition	60 (59.4)	49 (81.7)	11 (18.3)
Well-nourished	41 (40.6)	30 (73.2)	11 (26.8)
Referral status
Referred	52 (51.5)	41 (78.8)	11 (21.2)
Not referred	49 (48.5)	38 (77.6)	11 (22.4)
Primary organ system involved in the presenting diagnosis at admission
Respiratory	23 (22.8)	16 (69.6)	7 (30.4)
Neurology	15 (14.9)	14 (93.3)	1 (6.7)
Gastrohepatology	3 (3.0)	2 (66.7)	1 (33.3)
Cardiovascular	21 (20.8)	15 (71.4)	6 (28.6)
Hematology-oncology	10 (9.9)	10 (100.0)	0
Infection and tropical disease	2 (2.0)	2 (100.0)	0
Nutrition	1 (1.0)	1 (100.0)	0
Endocrinology	2 (2.0)	0	2 (100.0)
Immunology	6 (5.9)	6 (100.0)	0
Nephrology	10 (9.9)	7 (70.0)	3 (30.0)
Trauma	8 (7.9)	6 (75.0)	2 (25.0)
History of surgery
Yes	30 (29.7)	23 (76.7)	7 (23.3)
No	71 (70.3)	56 (78.9)	15 (21.1)
Blood culture result
Positive	8 (7.9)	8 (100)	0
Acinetobacter baumannii	1 (1)
Pseudomonas aeruginosa	2 (2)
Staphylococcus aureus	1 (1)
Staphylococcus capitis	1 (1)
Stenotrophomonas maltophilia	1 (1)
Streptococcus intermedius	1 (1)
Negative	93 (92.1)	71 (76.3)	22 (21.8)
Vasoactive-inotropic medication
Dopamine	3 (3)	2 (66.7)	1 (23.3)
Dobutamine	31 (30.7)	25 (80.0)	6 (20.0)
Epinephrine	79 (78.2)	64 (81.0)	15 (19.0)
Milrinone	7 (6.9)	7 (100.0)	0
Vasopressin	0	0	0
Norepinephrine	32 (31.7)	29 (90.0)	3 (10)
Number of vasoactive/inotropic
1	57 (56.4)	38 (66.7)	19 (33.3)
2	38 (37.6)	35 (92.1)	3 (7.9)
3	6 (5.9)	6 (100.0)	0
Mechanical ventilation
Yes	92 (91.1)	76 (82.6)	16 (17.4)
No	9 (8.9)	3 (33.6)	6 (66.7)
PELOD-2 score	10 (0–19)	12 (4–19)	7 (0–12)
VIS	20 (2–200)	25 (2–200)	10 (3–20)
Procalcitonin (ng/ml)	11.78 (0.04–2,311)	23.34 (0.13–2,311)	2.67 (0.04–343)
PICU length of stay (day)	6 (0–72)	5 (0–42)	10.5 (5–72)

Variable	Outcome		P-value^a)	OR^b)	95% CI
Variable	Non-survivor (n=79)	Survivor (n=22)	P-value^a)	OR^b)	95% CI
Age (yr)				-	-
<5	43 (74.1)	15 (25.9)	0.249
≥5	36 (83.7)	7 (16.3)
Sex				-	-
Boy	42 (79.2)	11 (20.8)	0.793
Girl	37 (77.1)	11 (22.9)
Nutritional status				-	-
Malnourished	49 (80.4)	11 (18.3)	0.310
Well-nourished	30 (73.2)	11 (26.8)
Referral				-	-
Referral	41 (78.8)	11 (21.2)	0.875
Not referral	38 (77.6)	11 (22.4)
History of surgery				-	-
Yes	23 (76.7)	7 (23.3)	0.806
No	56 (78.9)	15 (21.1)
Required mechanical ventilation			0.003	9.50	2.14–42.02
Yes	76 (82.6)	16 (17.4)
No	3 (33.3)	6 (66.7)
PELOD-2			<0.001	20.74	6.46–66.63
≥8	70 (92.1)	6 (7.9)
< 8	9 (36.0)	16 (64.0)
VIS			<0.001	9.73	3.30–28.67
≥11.5	62 (91.2)	6 (8.8)
< 11.5	17 (51.5)	16 (48.5)
Procalcitonin (ng/ml)			<0.001	6.32	2.26–17.72
≥5	59 (89.4)	7 (10.6)
<5	20 (57.1)	15 (42.9)

Variables in the equation		B	SE	Wald	dF	Sig.	Exp (B)	95% CI for Exp (B)
Step 1	PELOD-2	2.623	0.765	11.774	1	0.001	13.783	3.080–61.678
	Procalcitonin	1.442	0.663	4.733	1	0.030	4.231	1.154–15.516
	MV	–0.197	1.014	0.038	1	0.846	0.821	0.113–5.990
	VIS	1.569	0.675	5.407	1	0.020	4.800	1.280–18.007
	Constant	–1.809	0.877	4.252	1	0.039	0.164	-
Step 2	PELOD-2	2.551	0.665	14.703	1	0.000	12.822	3.481–47.238
	VIS	1.545	0.662	5.441	1	0.020	4.686	1.280–17.158
	Procalcitonin	1.446	0.663	4.756	1	0.029	4.245	1.158–15.566
	Constant	–1.923	0.660	8.486	1	0.004	0.146	-

Table 1. Demographic characteristics of the subjects

Values are presented as median (range) or number (%).

PELOD-2: Pediatric Logistic Organ Dysfunction-2; VIS: vasoactive-inotropic score; PICU: pediatric intensive care unit.

Table 2. Risk factors of mortality among pediatrics with septic shock on bivariate analysis

Values are presented as number (%).

OR: odd ratio; PELOD-2: Pediatric Logistic Organ Dysfunction-2; VIS: vasoactive-inotropic score.

P-value is based on bivariate analysis using chi-square test or fisher-exact test;

Possible risk factors with P<0.05 were included in multivariate analysis model using logistic regression.

Table 3. The final multivariate analysis using backward likelihood ratio methods

Equation of the scoring: y=–1.923+2.551 (PELOD-2)+1.545 (VIS)+1.446 (procalcitonin).