Cardiovascular

• Despite administration of isotonic intravenous fluid bolus ≥40 mL/kg in 1 hr: hypotension <5th percentile for age, or systolic BP <2 SD below normal for age or • Need for vasoactive drug to maintain BP in normal range (dopamine >5 µg/kg/min or dobutamine, epinephrine, or norepinephrine at any dose) or • Two of the following: Unexplained metabolic acidosis: base deficit >5.0 mEq/L Increased arterial lactate: >1 mmol/L or >2× upper limit of normal Oliguria: urine output <0.5 mL/kg/hr Prolonged capillary refill: >5 sec Core-to-peripheral temperature gap: >3°C (5.4°F)

Respiratory

•PaO2/FIO2 ratio <300 in absence of cyanotic heart disease or • preexisting lung disease or • PaCO2 >65 torr or 20 mm Hg over baseline PaCO2 or • Need for >50% FIO2 to maintain saturation ≥92% or Need for nonelective invasive or noninvasive mechanical ventilation

• GCS score ≤11 or • Acute change in mental status with decrease in GCS score ≥3 points from abnormal baseline

• Platelet count <80,000/mm3 or decline of 50% in platelet count from highest value recorded over last 3 days (for patients with chronic hematologic or oncologic disorders) or • INR >2 or • Activated prothrombin time >60 sec

Serum creatinine >0.5 mg/dL, ≥2× upper limit of normal for age, or 2-fold increase in baseline creatinine value

Total bilirubin ≥4 mg/dL (not applicable for newborn) Alanine transaminase level 2× upper limit of normal for age