Acute and Critical Care

Review Article

Ethics
When ethics is not enough: institutional governance of critical care allocation under crisis conditions: Ho Kyung Sung, Ungki Jung, Kyungdo Lee; Acute Crit Care. 2026;41(2):213-225. Published online May 28, 2026; DOI: https://doi.org/10.4266/acc.001872

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Ethical principles such as maximizing benefit, fairness, and procedural justice are frequently invoked in discussions on critical care resource allocation during public health emergencies. The coronavirus disease 2019 (COVID-19) pandemic, however, demonstrated that the mere presence of ethical principles does not ensure their operation in real-world crisis settings. In Lombardy and New York, allocation decisions defaulted to individual clinicians under extreme pressure. This review examines the institutional and governance prerequisites for ethical allocation of critical care resources during surge conditions. Rather than proposing normative allocation criteria, we analyze how ethical principles are translated—or fail to be translated—into practice through institutional arrangements. Using Ontario, Canada, as an empirical reference point, we conduct a comparative analysis of crisis standards of care, governance structures, regional coordination mechanisms, data infrastructures, and legal protections that support collective decision-making in critical care. We propose a multilevel analytical framework comprising three interdependent levels: national and governance, hospital and regional operations, and individual clinical application. Across international experiences, failures in critical care allocation arise when key functions are absent or misaligned across these levels, concentrating ethical, legal, and emotional burdens on frontline clinicians. Applying this framework to the Korean context, we identify structural gaps in crisis standard activation, governance authority, coordination mechanisms, and institutional decision-making capacity, indicating that ethical allocation is not solely a moral challenge, but a systems-level governance problem requiring institutional preparedness beyond ethical consensus.

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Towards Distributive Justice in Life-Sustaining Care: Navigating the Structural Determinants of Patient Preference
Ungki Jung, Ho Kyung Sung, Kyungdo Lee
Korean Journal of Medical Ethics.2026; 29(2): 99. CrossRef

Original Articles

Basic Science and Research
Developing consensus-based indicators for intensive care unit capacity and capability in South Korea: a modified Delphi study: Jeehye Lee, Ho Kyung Sung, Min-hwan Oh, Jin Young Kim, KyoungHo Kim, Jae Young Moon; Acute Crit Care. 2026;41(2):282-294. Published online May 28, 2026; DOI: https://doi.org/10.4266/acc.000676

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Abstract PDF Supplementary Material: Background
Intensive care units (ICUs) are essential components of modern healthcare systems, but South Korea lacks capability-based standards for ICU classification. Critically ill patients are frequently assigned based on bed availability rather than clinical need, creating mismatches between patient acuity and ICU capability. The aim of this study was to develop consensus-based indicators for assessing ICU capacity and capability in South Korea. Methods: A modified Delphi study was conducted with 24 multidisciplinary experts, including members of the Korean Society of Critical Care Medicine (SCCM) Standardization Committee. Based on a systematic review of international ICU frameworks (SCCM, European Society of Intensive Care Medicine, Australian and New Zealand Intensive Care Society), 42 candidate indicators across six domains were evaluated over three rounds (April–July 2025). Consensus was defined as a content validity ratio ≥ a preset critical threshold and ≥75% expert agreement. Results: The response rates were 79.2%–91.7% across rounds. The final framework comprises 29 indicators across four domains: Capacity (staffing, facilities, bed management), Capability (life support, specialized care), Human resources (physician and allied health coverage), and Space and equipment infrastructure (monitoring and safety systems). The experts prioritized functional capabilities over structural metrics: nurse-to-bed ratios were rated more important than physician numbers, and 24/7 service availability was prioritized over personnel counts. Ward support, education, and research indicators did not reach consensus. Conclusions: This study establishes the first expert consensus framework for ICU capability assessment in South Korea. The 29 indicators provide a foundation for a capability-oriented classification system that prioritizes patient safety and efficient resource allocation. Future research should validate these indicators against clinical outcomes and explore real-time ICU capacity monitoring strategies.

Epidemiology
The functional landscape of critical care: a nationwide study of volume, capability, and institutional variation in South Korea: Ho Kyung Sung, Jeehye Lee, Min-hwan Oh, Jin Young Kim, Young Kyun Choi, Jae Young Moon; Acute Crit Care. 2026;41(2):270-281. Published online April 15, 2026; DOI: https://doi.org/10.4266/acc.004225

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Abstract PDF Supplementary Material: Background
In Korea, intensive care units (ICUs) are defined mainly by administrative categories, which do not reflect functional capability. This study examined the relationship between hospital capacity and functional performance by analyzing nationwide patterns of volume, capability, and institutional variation. Methods: We analyzed adult emergency department-to-ICU admissions in 378 hospitals from 2016 to 2023. Admission and life-support intervention (LSI) volumes were measured; organ-supportive therapies such as mechanical ventilation and renal replacement therapy were considered LSIs, and the LSI rate (LSI admissions/total admissions) was used as a proxy for functional capability. Generalized additive models assessed non-linear relationships with bed capacity, and residual-based analysis was used to classify hospitals into functional phenotypes. Results: Critical care delivery was highly concentrated; the top 8% of hospitals provided 50% of LSIs. Admission and LSI volumes increased with hospital size but plateaued beyond approximately 1,300 beds, while the LSI rate continued to rise until approximately 1,700 beds. Hospitals of similar size showed wide variation in both volume and capability. Based on residuals, 42.4% of hospitals formed a central reference group, while others were classified as high-volume/high-capability (13.7%), low-volume/high-capability (15.0%), low-volume/low-capability (12.0%), or high-volume/low-capability (16.9%). Conclusions: The relationship between structural capacity and functional performance in Korean ICUs is complex and non-linear. Hospital size alone is insufficient to predict emergency critical care delivery, underscoring the importance of operational models alongside structural resources. These findings provide a foundation for capability-based ICU stratification to guide resource allocation and strengthen system resilience.

Basic Science and Research
Specification of Subject Sex in Oncology-Related Animal Studies: Sukyo Lee, Won Jun Kim, Yeong Jeon, Choon Hak Lim, Kyung Sun; Acute Crit Care. 2018;33(3):178-184. Published online August 31, 2018; DOI: https://doi.org/10.4266/acc.2017.00444

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Abstract PDF

Background
Growing evidence for clinically significant differences between the sexes has attracted the attention of researchers. However, failures to report a test animal sex and balance the sex ratios of study samples remain widespread in preclinical investigations. We analyzed the sex-reporting rate and sex distributions of test animals in published oncology studies.
Methods
We selected five oncology journals included in the Scientific Citation Index (SCI) based on impact factors. We identified preclinical investigations with in vivo mouse experiments published in 2015 for inclusion in our study sample. We classified each article by whether or not it reported test subject sex, and by which sex was included. We also recorded whether there were justifications for using one particular sex in single-sex studies (e.g., anatomical reasons) and whether sex-based analyses were conducted for both-sex studies.
Results
We surveyed a total of 382 articles. Half (50.3%) failed to report test animal sex. Among articles that did report sex, 91.7% were single-sex studies, of which 69.4% did not provide any justifications for using the sex included in the study. Relatively few studies 15.7 studies included animals of both sexes, and only 2.3 studies conducted sex-based analyses. These findings are consistent with those of previous research that used other methods to collect data from the literature such as text mining, but our analysis of the provision of justifications for using one sex versus the other is a novel feature.
Conclusions
Many researchers overlook test subject sex as a factor, but test animal sex should be reported in all preclinical investigations to enhance the reproducibility of research and avoid faulty conclusions drawn from one-sided studies.

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Pyrimethamine reduced tumour growth in pre-clinical cancer models: a systematic review to identify potential pre-clinical studies for subsequent human clinical trials
Sivananthan Manoharan, Lee Ying Ying
Biology Methods and Protocols.2024;[Epub] CrossRef

Case Reports

Surgical Management for Pulmonary Artieriole Rupture During Subclavian Vein Catheterization: A Case Report: Jiae Min, Hyun Koo Kim, Ho Kyung Sung, Hyun Joo Lee, Young Ho Choi; Korean J Crit Care Med. 2012;27(1):59-61.; DOI: https://doi.org/10.4266/kjccm.2012.27.1.59

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Abstract PDF: We experienced an extremely unusual case of a 37-year-old woman who suffered from hemothorax soon after subclavian vein catheterization. Many case reports of a hemothorax or hematoma after central vein catheterization through the great vessels, such as the subclavian vein and internal jugular vein, have been published. However, this rare case showed a pinpoint-sized active bleeding site from a pulmonary arteriole rupture. During an emergency operation using thoracoscopy-assisted minithoracotomy, this bleeding site was successfully managed by primary repair.

Takotsubo Cardiomyopathy Induced after Postoperative ICU Care: Case Reports: Kuk Hui Son, Jae Seung Jung, Kwang Taik Kim, Kyung Sun, Ho Sung Son, Jae Yoon Song, Yong Hyun Kim, Sung Ho Lee; Korean J Crit Care Med. 2009;24(3):152-155.; DOI: https://doi.org/10.4266/kjccm.2009.24.3.152

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Abstract PDF

'Takotsubo cardiomyopathy' or 'stress-induced cardiomyopathy' is a newly described clinical entity that's characterized by transient left ventricular apical ballooning and left ventricular apical dyskinesis in the absence of any angiographic feature of significant coronary artery disease. The cause of takotsubo cardiomyopathy is unclear, but catecholamines probably play a role in the genesis of takotsubo cardiomyopathy. We report here on two cases of takotsubo cardiomyopathy that occurred during ICU care.

Citations

Citations to this article as recorded by

Stress-induced Cardiomyopathy Following Cesarean Delivery with Hemorrhagic Shock - A Case Report -
Youn Yi Jo, Ja Young Kwon, Yoon-Seong Jang, Yong Seon Choi
The Korean Journal of Critical Care Medicine.2011; 26(1): 34. CrossRef

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