Acute and Critical Care

Volume 40 (1); February 2025

Review Articles

Nephrology
Dialysis decision in critically ill patients in intensive care unit: Harin Rhee; Acute Crit Care. 2025;40(1):1-9. Published online February 28, 2025; DOI: https://doi.org/10.4266/acc.004896

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Abstract PDF: The 2012 Kidney Disease Improving Global Outcomes guidelines clearly define emergent indications for kidney replacement therapy; however, whether dialysis should be initiated in critically ill patients without these indications remains unclear. This review briefly summarizes the results of recent landmark trials and discusses their limitations originating from a criteria-based approach at a single time point. Moreover, a personalized approach based on each patient’s demand-capacity balance and its future benefits as a platform for kidney support therapy in critically ill patients are discussed.

Nursing
Promoting patient safety in critically ill patients: nursing interventions in surveillance and prevention of ocular injuries: Anabela Carvalho Raposo, Maria Candida Durao, Maria do Rosário Pinto, Helga Rafael Henriques, Joana Ferreira Teixeira; Acute Crit Care. 2025;40(1):10-17. Published online February 12, 2025; DOI: https://doi.org/10.4266/acc.005014

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Abstract PDF: Corneal surface injuries occur frequently (59.4%) in critically ill patients, and the average time for their appearance is 8 days. Such injuries are primarily related to dry eye, which increases the risk of exposure injury in patients admitted to intensive care units. This can result in a severe ulcer or perforation that results in partial to total loss of vision, decreasing the quality of the patient's life. This is a sensitive nursing care area requiring further investigation. Thus, this review aims to analyse nursing interventions that aim to prevent ocular surface injuries. An integrative literature review was carried out from May to August 2023 in the Medline, CINAHL, Scopus, Web of Science, and PubMed databases using the Whittemore and Knafl methodology. Inclusion and exclusion criteria were subsequently applied to assess the results. After verifying result eligibility, seven documents were identified for data extraction and analysis. The results suggest the importance of recognizing risk factors for ocular injuries in critically ill patients, surveillance as a nursing competency, adequate ocular hygiene and effective lubrication, and managing environmental conditions to prevent corneal injuries. Implementing surveillance and intervention protocols for critically ill patients at risk of corneal injuries requires specialized training for critical care nurses. Specifically, environmental management, including temperature and humidity control, is highlighted as an area that merits further research.

Original Articles

Epidemiology
Simulating the effects of reducing transfer latency from the intensive care unit on intensive care unit bed utilization in a Korean Tertiary Hospital: Jaeyoung Choi, Song-Hee Kim, Ryoung-Eun Ko, Gee Young Suh, Jeong Hoon Yang, Chi-Min Park, Joongbum Cho, Chi Ryang Chung; Acute Crit Care. 2025;40(1):18-28. Published online February 21, 2025; DOI: https://doi.org/10.4266/acc.002976

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Abstract PDF Supplementary Material: Background
Latency in transferring patients from intensive care units (ICUs) to general wards impedes the optimal allocation of ICU resources, underscoring the urgency of initiatives to reduce it. This study evaluates the extent of ICU transfer latency and assesses the potential benefits of minimizing it.
Methods
Transfer latency was measured as the time between the first transfer request and the actual ICU discharge at a single-center tertiary hospital in 2021. Computer-based simulations and cost analyses were performed to examine how reducing transfer latency could affect average hourly ICU bed occupancy, the proportion of time ICU occupancy exceeds 80%, and hospital costs. The first analysis evaluated all ICU admissions, and the second analysis targeted a subset of ICU admissions with longer transfer latency, those requiring infectious precautions.
Results
A total of 7,623 ICU admissions were analyzed, and the median transfer latency was 5.7 hours. Eliminating transfer latency for all ICU admissions would have resulted in a 32.8% point decrease in the proportion of time ICU occupancy exceeded 80%, and a potential annual savings of $6.18 million. Eliminating transfer latency for patients under infectious precautions would have decreased the time ICU occupancy exceeded 80% by 13.5% points, and reduced annual costs by a potential $1.26 million.
Conclusions
Transfer latency from ICUs to general wards might contribute to high ICU occupancy. Efforts to minimize latency for all admissions, or even for a subset of admissions with particularly long transfer latency, could enable more efficient use of ICU resources.

Rapid response system
Resident and nurse attitudes toward a rapid response team in a tertiary hospital in South Korea: Sung Yoon Lim, Ho Geol Woo, Jong Sun Park, Young-Jae Cho, Jae Ho Lee, Yeon Joo Lee; Acute Crit Care. 2025;40(1):29-37. Published online February 12, 2025; DOI: https://doi.org/10.4266/acc.004272

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Abstract PDF Supplementary Material: Background
Residents and nurses who activate rapid response teams (RRTs) are well positioned to offer insights on its effectiveness. Here, we assess such evaluation of RRTs and identify barriers to activation in a 1,400-bed teaching hospital.
Methods
We conducted a 24-item Likert-scale survey from January to May 2017 among residents and ward nurses with RRT experience. Factor analysis was used to identify the barriers.
Results
This study comprised 305 nurses and 53 residents, most of whom were satisfied with their RRT experiences. Factor analysis showed that lack of awareness of activation criteria was a major barrier, with only 21.4% and 22.2% participants, respectively, confident about their knowledge of activation protocols. Of the survey respondents, 85.7% reported first contacting the doctor before activating the RRT. Despite the protocol, 66.7% first discussed the decision with other staff, and 71.5% called the RRT when the patient’s condition worsened despite management.
Conclusions
Nurses and residents value RRTs but face barriers in initiation, primarily due to a lack of confidence in applying the activation criteria. Many prefer to consult a doctor or manage the patient before calling the RRT.

Infection
The association between defecation frequency and mortality in critically ill patients with suspected sepsis in Israel: Michael Roimi, Anat Shrot, Roy Ilan, Avraham Tenenbaum, Danny Epstein, Yaron Bar-Lavie; Acute Crit Care. 2025;40(1):38-45. Published online February 18, 2025; DOI: https://doi.org/10.4266/acc.000696

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Abstract PDF: Background
The pivotal role of the gastrointestinal (GI) tract in sepsis is well recognized. This study aimed to evaluate the associations between defecation frequency as a basic assessment of GI function and the clinical outcomes of intensive care unit patients with suspected sepsis.
Methods
This retrospective, single-center study included patients suspected of having sepsis. The number of defecations and consecutive days without defecation during the 72 hours preceding the suspected infection were assessed. The primary outcome was 30-day all-cause mortality. Multivariate regression analysis adjusting for potential confounders was employed to establish the associations between GI function and clinical outcomes.
Results
The final analysis included 1,306 patients with a median age of 56.2 years (interquartile range [IQR], 39.6–69.1); 919 (70.4%) were male, and the median Acute Physiology and Chronic Health Evaluation II score was 22.0 (IQR, 17.0–27.0). The median Sequential Organ Failure Assessment score at the time of suspected infection was 5.0 (IQR, 3.0–7.0). Mortality rates were 20.3%, 28.0%, and 34.3% for patients with 0–2, 3–5, and >5 defecations, respectively (P<0.001). There was a strong correlation between the number of defecations and mortality (r=0.7, P=0.01). In multivariate analyses, each defecation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.07; 95% CI, 1.01–1.12; P=0.01), while each consecutive day without a defecation was associated with reduced mortality (aOR, 0.83; 95% CI, 0.73–0.96; P=0.01).
Conclusions
A higher number of defecations in the 72 hours preceding suspected sepsis is associated with increased 30-day all-cause mortality, suggesting a potential association with GI tract dysfunction.

Basic science and research
Impact of tadalafil on cardiovascular and organ dysfunction induced by experimental sepsis: Marcelo Almeida Nakashima, Gabrielle Delfrate, Lucas Braga Albino, Gustavo Ferreira Alves, Junior Garcia Oliveira, Daniel Fernandes; Acute Crit Care. 2025;40(1):46-58. Published online February 12, 2025; DOI: https://doi.org/10.4266/acc.002904

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Abstract PDF: Background
Sepsis is a life-threatening condition that affects the cardiovascular and renal systems. Severe hypotension during sepsis compromises tissue perfusion, which can lead to multiple organ dysfunction and death. Phosphodiesterase 5 (PDE5) degrades intracellular cyclic guanosine monophosphate (cGMP) levels which promotes vasodilatation in specific sites. Our previous studies show that inhibiting cGMP production in early sepsis increases mortality, implying a protective role for cGMP production. Then, we hypothesized that cGMP increased by tadalafil (PDE5 inhibitor) could improve microcirculation and prevent sepsis-induced organ dysfunction.
Methods
Rats were submitted to cecal ligation and puncture (CLP) sepsis model and treated with tadalafil (2 mg/kg, s.c.) 8 hours after the procedure. Hemodynamic, inflammatory and biochemical assessments were performed 24 hours after sepsis induction. Moreover, the effect of tadalafil on the survival of septic rats was evaluated for 5 days.
Results
Tadalafil treatment improves basal renal blood flow during sepsis and preserves it during noradrenaline infusion. Sepsis induces hypotension, impaired response to noradrenaline, and increased cardiac and renal neutrophil infiltration, in addition to increased levels of plasma nitric oxide and lactate. None of these dysfunctions were changed by tadalafil. Additionally, tadalafil treatment did not increase the survival rate of septic rats.
Conclusions
Tadalafil improved microcirculation of septic animals; however, no beneficial effects were observed on macrocirculation and inflammation parameters. Then, the potential benefit of tadalafil in the prognosis of sepsis should be evaluated within a therapeutic strategy covering all sepsis injury mechanisms.

Neurosurgery
A low preoperative platelet-to-white blood cell ratio is associated with acute kidney injury following cerebral aneurysm treatment in South Korea: Seung-Woon Lim, Woo-Young Jo, Hee-Pyoung Park; Acute Crit Care. 2025;40(1):59-68. Published online February 21, 2025; DOI: https://doi.org/10.4266/acc.003120

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Abstract PDF Supplementary Material: Background
Inflammation is involved in the pathophysiology of postoperative acute kidney injury (AKI). We investigated whether preoperative platelet-to-white blood cell ratio (PWR), a novel serum biomarker of systemic inflammation, was associated with postoperative AKI following cerebral aneurysm treatment. We also compared the discrimination power of preoperative PWR with those of other preoperative systemic inflammatory indices in predicting postoperative AKI.
Methods
Perioperative data including preoperative systemic inflammatory indices and cerebral aneurysm-related variables were retrospectively analyzed in 4,429 cerebral aneurysm patients undergoing surgical clipping or endovascular coiling. Based on the cutoff value of preoperative PWR, patients were divided into the high PWR (≥39.04, n=1,924) and low PWR (<39.04, n=2,505) groups. After propensity score matching (PSM), 1,168 patients in each group were included in the data analysis. AKI was defined according to the Kidney Disease Improving Global Outcomes guidelines.
Results
Postoperative AKI occurred more frequently in the low PWR group than in the high PWR group before PSM (45 [1.8%] vs. 7 [0.4%], P<0.001) and after (17 [1.5%] vs. 5 [0.4%], P=0.016). A low preoperative PWR was predictive of postoperative AKI before PSM (odds ratio [95% CI], 3.93 [1.74–8.87]; P<0.001) and after (3.44 [1.26–9.34], P=0.016). Preoperative PWR showed the highest area under the curve for postoperative AKI (0.713 [0.644–0.782], P<0.001), followed by preoperative platelet-to-neutrophil ratio (0.694 [0.619–0.769], P<0.001), neutrophil percentage-to-albumin ratio (0.671 [0.592–0.750], P<0.001), white blood cell-to-hemoglobin ratio (0.665 [0.579–0.750], P<0.001), neutrophil-to-lymphocyte ratio (0.648 [0.569–0.728], P<0.001), and systemic inflammatory index (0.615 [0.532–0.698], P=0.004).
Conclusions
A low preoperative PWR was associated with postoperative AKI following cerebral aneurysm treatment.

Neurosurgery
Cost-effectiveness of intracranial pressure monitoring in severe traumatic brain injury in Southern Thailand: Jidapa Jitchanvichai, Thara Tunthanathip; Acute Crit Care. 2025;40(1):69-78. Published online February 21, 2025; DOI: https://doi.org/10.4266/acc.004080

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Abstract PDF Supplementary Material: Background
Traumatic brain injury (TBI) is a leading cause of fatalities and disabilities in the public health domain, particularly in Thailand. Guidelines for TBI patients advise intracranial pressure monitoring (ICPm) for intensive care. However, information about the cost-effectiveness (CE) of ICPm in cases of severe TBI is lacking. This study assessed the CE of ICPm in severe TBI.
Methods
This was a retrospective cohort economic evaluation study from the perspective of the healthcare system. Direct costs were sourced from electronic medical records, and quality-adjusted life years (QALY) for each individual were computed using multiple linear regression with standardization. Incremental costs, incremental QALY, and the incremental CE ratio (ICER) were estimated, and the bootstrap method with 1,000 iterations was used in uncertainty analysis.
Results
The analysis included 821 individuals, with 4.1% undergoing intraparenchymal ICPm. The average cost of hospitalization was United States dollar ($)8,697.13 (±6,271.26) in both groups. The incremental cost and incremental QALY of the ICPm group compared with the non-ICPm group were $3,322.88 and –0.070, with the base-case ICER of $–47,504.08 per additional QALY. Results demonstrated that 0.007% of bootstrapped ICERs were below the willingness-to-pay (WTP) threshold of Thailand.
Conclusions
ICPm for severe TBI was not cost-effective compared with the WTP threshold of Thailand. Resource allocation for TBI prognosis requires further development of cost-effective treatment guidelines.

Thoracic Surgery
Connective tissue disease is associated with the risk of posterior reversible encephalopathy syndrome following lung transplantation in Korea: Tae Jung Kim, Hyun Joo Lee, Samina Park, Sang-Bae Ko, Soo-Hyun Park, Seung Hwan Yoon, Kwon Joong Na, In Kyu Park, Chang Hyun Kang, Young Tae Kim, Sun Mi Choi, Jimyung Park, Joong-Yub Kim, Hong Yeul Lee; Acute Crit Care. 2025;40(1):79-86. Published online January 7, 2025; DOI: https://doi.org/10.4266/acc.003384

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Abstract PDF Supplementary Material: Background
Posterior reversible encephalopathy syndrome (PRES) is a rare complication of lung transplantation with poorly understood risk factors and clinical characteristics. This study aimed to examine the occurrence, risk factors, and clinical data of patients who developed PRES following lung transplantation.
Methods
A retrospective analysis was conducted on 147 patients who underwent lung transplantation between February 2013 and December 2023. The patients were diagnosed with PRES based on the clinical symptoms and radiological findings. We compared the baseline characteristics and clinical information, including primary lung diseases and immunosuppressive therapy related to lung transplantation operations, between the PRES and non-PRES groups.
Results
PRES manifested in 7.5% (n=11) of the patients who underwent lung transplantation, with a median onset of 15 days after operation. Seizures were identified as the predominant clinical manifestation (81.8%, n=9) in the group diagnosed with PRES. All patients diagnosed with PRES recovered fully. Patients with PRES were significantly associated with connective tissue disease-associated interstitial lung disease (45.5% vs. 18.4%, P=0.019, odds ratio=9.808; 95% CI, 1.064–90.386; P=0.044). Nonetheless, no significant variance was observed in the type of immunotherapy, such as the use of calcineurin inhibitors, blood pressure, or acute renal failure subsequent to lung transplantation.
Conclusions
PRES typically manifests shortly after lung transplantation, with seizures being the predominant initial symptom. The presence of preexisting connective tissue disease as the primary lung disease represents a significant risk factor for PRES following lung transplantation.

Trauma
Predictive value of initial lactate levels for mortality and morbidity in critically ill pediatric trauma patients: a retrospective study from a Turkish pediatric intensive care unit: Abdulrahman Özel, Esra Nur İlbeği, Servet Yüce; Acute Crit Care. 2025;40(1):87-94. Published online February 18, 2025; DOI: https://doi.org/10.4266/acc.003528

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Abstract PDF: Background
This study investigated the relationship between initial lactate levels and both mortality and morbidity in critically ill pediatric trauma patients requiring intensive care.
Methods
This retrospective study at tertiary center’s pediatric intensive care unit from January 2020 to June 2024 aimed to characterize trauma patients and assess admission lactate levels' prognostic value.
Results
A total of 190 critically ill pediatric trauma patients were included in the study. The mortality rate was 7.9%, with most deaths occurring within the first 48 hours of admission. Initial lactate levels ≥6.9 mmol/L demonstrated moderate predictive power (area under the curve [AUC], 0.878) for mortality. Pediatric Risk of Mortality III (PRISM III) score showed good predictive ability (AUC, 0.922), while Pediatric Trauma Scores exhibited variable predictive performance (AUC, 0.863). Higher initial lactate levels were significantly associated with severe brain injury, the need for intubation, and an increased incidence of thoracic or abdominal injuries.
Conclusions
Initial lactate levels and PRISM III score are effective predictors of mortality in critically ill pediatric trauma patients. Lactate levels ≥5 mmol/L upon admission should prompt close monitoring and consideration of aggressive management strategies.

Trauma
Effect of atorvastatin as a renal protective agent in patients with systemic inflammatory response syndrome using the renal arterial resistive index: Mina Maher Raouf, Eslam Antar Shadad, Nagy Sayed Ali; Acute Crit Care. 2025;40(1):95-104. Published online February 18, 2025; DOI: https://doi.org/10.4266/acc.003912

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Abstract PDF: Background
Current meta-analyses have yielded inconclusive results regarding the effectiveness of statins in preventing early renal injury in the context of poly-trauma. Notably, renal artery Doppler-derived resistance indices have shown a strong correlation with early detection of renal impairment, underscoring their importance in clinical assessment.
Methods
The study involved 106 adults aged 18 years and older of both sexes, who presented to Minia University Hospital, Egypt, with poly-trauma with a two-point or greater increase in the sequential organ failure assessment score within the first 72 hours of hospital admission and who met two or more of the diagnostic criteria of systemic inflammatory response syndrome. Participants were randomly assigned to either the atorvastatin group, which received oral atorvastatin at a dosage of 20 mg every 12 hours for 1 week alongside conventional therapy (antimicrobial agents and balanced crystalloids), or the control group, which received conventional therapy along with a placebo tablet every 12 hours for 1 week.
Results
The atorvastatin group yielded a significantly lower incidence of acute kidney injury (AKI; P<0.001). Additionally, there was significant reduction in renal resistance and pulsatility indices in the atorvastatin group. Furthermore, the atorvastatin group exhibited a shorter intensive care unit (ICU) stay (P=0.004). The renal index had a sensitivity of 90% and specificity of 68% for AKI prediction when the cutoff value was 0.61. Pulsatility index had a sensitivity of 90% and a specificity of 53% when the cutoff value was 1.28.
Conclusions
Atorvastatin was impactful in mitigating the incidence of AKI, improving renal resistive vascular indices, and abbreviating ICU stays in the poly-traumatized population.

Pediatrics
Hyper- and hypomagnesemia as an initial predictor of outcomes in septic pediatric patients in Egypt: Aya Osama Mohamed; Acute Crit Care. 2025;40(1):105-112. Published online February 4, 2025; DOI: https://doi.org/10.4266/acc.000480

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Abstract PDF: Background
Critically ill septic children are susceptible to electrolyte abnormalities, including magnesium disturbance, which can easily be neglected. This study examined the potential correlation between serum magnesium levels upon admission to the pediatric intensive care unit (PICU) and the outcomes of critically ill septic patients.
Methods
This prospective study, conducted from May 2023 to November 2023, included 76 children with sepsis who underwent clinical and lab assessments that included initial magnesium levels. The outcome of sepsis was documented. Predictors of mortality were identified through multivariate logistic regression models, with discrimination and calibration assessed using the area under the curve (AUC).
Results
The median magnesium level upon PICU admission was 2.0 mg/dl (range 1.1–4.9), and it was slightly higher in non-survivors than survivors (2.1 mg/dl; interquartile range [IQR], 1.9–2.5 vs. 2.0; IQR, 1.8–2.6, respectively), Hypermagnesemia was observed to have a negative effect on critically ill septic patients. It was also found that hypermagnesemia was associated with low C-reactive protein levels (P=0.043). With a cutoff of 5.5, the pediatric Sequential Organ Failure Assessment score strongly predicted mortality (AUC=0.717, P<0.001), with a sensitivity of 64.3% and specificity of 68.8%.
Conclusions
As an initial predictor of mortality, the serum magnesium level cannot be used alone; however, hypermagnesemia has a negative impact on critically ill septic patients. Thus, healthcare professionals should be cautious with magnesium administration.

Pediatrics
Effects of rescue airway pressure release ventilation on mortality in severe pediatric acute respiratory distress syndrome: a retrospective comparative analysis from India: Sudha Chandelia, Sunil Kishore, Maansi Gangwal, Devika Shanmugasundaram; Acute Crit Care. 2025;40(1):113-121. Published online February 28, 2025; DOI: https://doi.org/10.4266/acc.002520

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Abstract PDF: Background
Pediatric acute respiratory distress syndrome (PARDS) has a mortality rate of up to 75%, which can be up to 90% in high-risk patients. Even with the use of advanced ventilation strategies, mortality remains unacceptably high at 40%. Airway pressure release ventilation (APRV) mode is a new strategy in PARDS. Our aim was to evaluate whether use of APRV mode in severe PARDS was associated with reduced hospital mortality compared to other modes of ventilation.
Methods
This was a retrospective comparative study using data from case files in a pediatric intensive care unit of a university-affiliated tertiary-care hospital. The study period (January 2014 to December 2019) covered three years before routine use of APRV mode to three years after its implementation. We compared severe PARDS patients in two groups: The APRV group (who received APRV as rescue therapy after failing protective ventilation); and The Non-APRV group, who received other modes of ventilation.
Results
A total of 24 patients in each group were analyzed. Overall in-hospital mortality in the APRV group was 79% versus 91% in the Non-APRV group. In-hospital mortality was significantly lower in the APRV group (univariate analysis: hazard ratio [HR], 0.27; 95% CI, 0.14–0.52; P=0.001 and multivariate analysis: HR, 0.03; 95% CI, 0.005–0.17; P=0.001). Survival times were significantly longer in the APRV group (median time to death: 7.5 days in APRV vs. 4.3 days in non-APRV; P=0.001).
Conclusions
Use of rescue APRV mode in severe PARDS may yield lower mortality rates and longer survival times.

Pediatrics
Acute severe hepatitis in children following extrahepatic infection in South Korea: etiology, clinical course, and outcomes: Sanghoon Lee, Young Ok Kim, Seo-Hee Kim; Acute Crit Care. 2025;40(1):122-127. Published online February 28, 2025; DOI: https://doi.org/10.4266/acc.000600

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Abstract PDF: Background
Acute hepatitis can occur in association with systemic diseases outside the liver. Acute severe hepatitis with markedly elevated transaminase levels following extrahepatic infection has been reported in children. However, research on this condition remains limited. This study aimed to investigate its etiology, clinical course, and outcomes.
Methods
We retrospectively reviewed data from 2013 to 2020 for children under 12 years old with elevated liver enzymes following systemic infection. Acute severe hepatitis was defined as serum transaminase levels exceeding 1,000 IU/L in the absence of underlying liver disease. We analyzed hepatitis-associated pathogens, liver enzyme trends, and factors influencing recovery.
Results
A total of 39 patients were included in this study. The most common age group was 7–12 months (54.8%), and 53.8% were male. Respiratory infections were the most common (61.5%), followed by gastrointestinal infections (23.1%), meningitis (10.3%), and urinary tract infections (5.1%). The median peak alanine transaminase (ALT) level was 1,515.8±424.2 IU/L, with a median time to peak ALT of 4.2±2.3 days from symptom onset. ALT levels normalized within 21 days in 71.8% of patients and within 28 days in 94.9%. Younger age was associated with delayed ALT normalization, whereas hepatoprotective agent use was associated with faster normalization.
Conclusions
Acute severe hepatitis can develop following respiratory and other systemic infections. Younger children were more susceptible and had a more prolonged disease course.

Nursing
Nurses’ knowledge, attitude, and perceived barriers toward protective lung strategies of pediatrics mechanically ventilated patients in a tertiary care hospital in Pakistan: Tasnim Zainib, Salma Rattani, Nimira Asif, Hussain Maqbool Ahmed Maqbool; Acute Crit Care. 2025;40(1):128-135. Published online February 19, 2025; DOI: https://doi.org/10.4266/acc.004761

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Abstract PDF Supplementary Material: Background
Protective lung strategies (PLS) are guidelines about recent clinical advances that deliver an air volume compatible with the patient’s lung capacity and are used to treat acute respiratory distress syndrome. These mechanical ventilation guidelines are not implemented within intensive care units (ICUs) despite strong evidence-based recommendations and a dedicated professional staff. Nurses’ familiarity with clinical guidelines can bridge the gap between actual and recommended practice. However, several barriers undermine this process. The objectives of this study were to identify those barriers and explore the knowledge, attitudes, and behavior of ICU nurses regarding the implementation of PLS.
Methods
This was a descriptive, cross-sectional study. The participants were nurses working in the six ICUs of a pediatric tertiary care hospital in Lahore, Pakistan. Using purposive sampling with random selection, the total sample size was 137 nurses. A summative rating scale was used to identify barriers to the implementation of PLS.
Results
Overall, the nurses’ barrier score was high, with a mean of 66.77±5.36. Across all the barriers subscales, attitude was a much more significant barrier (35.74±3.57) to PLS than behavior (6.53±1.96), perceived knowledge (17.42±2.54), and organizational barriers (7.08±1.39). Knowledge-related barriers were also significantly high.
Conclusion
This study identified important barriers to PLS implementation by nurses, including attitudes and knowledge deficits. Understanding those barriers and planning interventions to address them could help to increase adherence to low tidal volume ventilation and improve patient outcomes. Nurses’ involvement in mechanical ventilation management could help to safely deliver air volumes compatible with recommendations.

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