Association of Admission Diastolic Shock Index with Subsequent Organ Dysfu nction and Mortality in Children with Sepsis: A Prospective Cohort Study

Background Early recognition of high-risk children with sepsis remains challenging because comprehensive organ dysfunction assessments are not always immediately available. The diastolic shock index (DSI), calculated as heart rate divided by diastolic blood pressure (DBP), is readily derived from routine vital signs and may serve as an accessible adjunct for early risk stratification. We evaluated whether DSI at pediatric intensive care unit (PICU) admission was associated with 28-day mortality and subsequent organ dysfunction during the first 24 hours. Methods This single-center prospective observational cohort study enrolled children aged 18 years or younger with suspected infection and organ dysfunction in a tertiary PICU in China from July 2022 to June 2025. DSI was calculated from the first valid paired heart rate and DBP measurement at admission. The primary outcome was 28-day all-cause mortality; the secondary outcome was the 24-hour pediatric Sequential Organ Failure Assessment (pSOFA) score. Cox regression, multivariable linear regression, restricted cubic spline models, Kaplan-Meier analysis, and exploratory mediation analysis were used. Results Among 152 children, 35 (23.0%) died within 28 days. In the fully adjusted Cox model, each 1-unit increase in DSI was associated with a higher hazard of death (hazard ratio, 1.38; 95% confidence interval, 1.02–1.86; p = 0.038). Each 1-unit increase in DSI was also associated with a 0.80-point higher 24-hour pSOFA score (standard error, 0.27; p = 0.003). Mortality risk and pSOFA score rose steadily across the observed DSI range. The indirect pathway through pSOFA was significant in the exploratory mediation analysis. Conclusions Higher admission DSI was associated with increased 28-day mortality and greater organ dysfunction during the first 24 hours. Admission Admission DSI was associated with subsequent organ dysfunction and 28-day mortality, suggesting its potential value as an early hemodynamic risk marker in children with sepsis. Multicenter validation and evaluation of serial measurements are required.