1. Saul Flores, MD* 2. Paul A. Checchia, MD, FCCM, FACC* 1. *Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX * Abbreviations: AKI: : acute kidney injury ARDS: : acute respiratory distress syndrome ECMO: : extracorporeal membrane oxygenation ICU: : intensive care unit IV: : intravenous MH: : malignant hyperthermia NIRS: : near-infrared spectroscopy PALS: : pediatric advanced life support PEWS: : pediatric early warning score RRT: : rapid response team SF: : systemic failure Early recognition of impending systemic failure is critical for timely interventions. However, some evidence demonstrates lower identification rates of impending systemic failure by primary care and emergency department physicians. After completing this article, readers should be able to: 1. Discuss how impending systemic failure (SF) presentation varies by age. 2. Delineate the epidemiological risk factors for the development of impending SF. 3. List the signs and symptoms of impending SF. 4. Recognize the laboratory findings associated with impending SF. 5. Define the various types of SF. 6. Describe the physiological parameters used to monitor critically ill patients at risk for impending SF. 7. Plan the management of impending SF. 8. Describe measures to prevent the development of SF. 9. Describe the implementation of rapid response teams. 10. Identify irreversible systemic failure (eg, brain death, hepatic failure, cardiogenic shock). You are the senior resident on call and part of the rapid response team (RRT) this evening. You are about to evaluate a 10-month-old infant in the pediatric inpatient ward after the parents activated the RRT. The patient’s bedside nurse informs you that for the past hour, the patient is more tachycardic and tachypneic and is febrile to 101.3°F (38.5°C) with increase of the pediatric early warning score (PEWS). In addition, the patient’s mother discloses that she has not had to change any diapers in the past 3 hours, and she also noticed the patient’s abdomen becoming more enlarged. The infant’s physical examination findings are a gallop, intermittent wheezing, and hepatosplenomegaly. The infant’s laboratory findings are creatinine level of 0.9 mg/dL (79.56 μmol/L), …