ICU nursing reference: critical care fundamentals for nursing students

ICU nursing is the specialty practice of caring for patients with life-threatening conditions who require continuous monitoring, advanced technology, and complex pharmacologic management. ICU nurses manage invasive lines, ventilators, vasopressors, and sedation protocols while serving as the primary clinical eyes on patients who cannot advocate for themselves. Nurse-to-patient ratios are 1:1 or 1:2, compared to 1:4–6 on general medical floors. The cognitive and technical demands are substantially higher, and the margin for error is narrower.

This reference covers the core clinical foundations of critical care nursing: hemodynamic monitoring, ventilator management, vasopressors, sedation and analgesia, CRRT, and systematic ICU assessment frameworks. Use it alongside the ARDS nursing reference, sepsis nursing guide, AKI reference, and ABG interpretation guide.

What ICU nurses do – and how ICU nursing differs from floor nursing

ICU nurses manage unstable, critically ill patients who require moment-to-moment physiologic surveillance. Core responsibilities include: continuous hemodynamic monitoring via arterial lines and central venous catheters; managing mechanical ventilation and responding to alarms; titrating vasoactive infusions to MAP targets; monitoring sedation depth and performing daily sedation vacations; coordinating care with intensivists, respiratory therapy, pharmacy, and PT/OT; performing comprehensive head-to-toe assessments every 1–2 hours; preventing VAP, CLABSI, CAUTI, and pressure injuries; and implementing the ABCDEF bundle.

Floor nursing operates on a higher ratio (1:4–6), with patients who are physiologically more stable and require less frequent reassessment. The critical distinctions are:

ICU types. The major ICU subtypes reflect patient population rather than nursing skill set – the core competencies transfer across units:

• MICU (Medical ICU): sepsis, respiratory failure, overdose, ARDS, metabolic crises
• SICU (Surgical ICU): post-operative complications, trauma surgery, bowel perforation
• CVICU (Cardiovascular ICU): post-cardiac surgery, STEMI with cardiogenic shock, IABP/ECMO management
• NICU (Neonatal ICU): premature infants, congenital anomalies, neonatal respiratory failure
• NSICU (Neuroscience ICU): stroke, TBI, subarachnoid hemorrhage, status epilepticus
• Trauma ICU: polytrauma, hemorrhagic shock, crush injuries

AACN CCRN certification is the primary credential for adult critical care nurses. AACN publishes two alternate eligibility routes under the Direct Care pathway, and they are easy to conflate:

• Two-year route: 1,750 hours in direct care of acutely or critically ill adult patients during the previous two years, with 875 of those hours in the most recent year preceding application.
• Five-year route: 2,000 hours during the previous five years, with 144 of those hours in the most recent year preceding application.

The exam covers cardiovascular, pulmonary, neurology, renal, endocrine, and multisystem content. Sub-specialty credentials include CCRN-K for knowledge professionals in non-bedside roles (a separate pathway requiring 1,040 hours over two years, 260 in the most recent year), CCRN-E for tele-critical care, and subspecialty exams for neonatal and pediatric critical care.

Hemodynamic monitoring

Hemodynamic monitoring measures the pressures and flows that drive oxygen delivery to tissues. In ICU patients, inadequate delivery causes end-organ dysfunction – the goal is to detect and correct hemodynamic deterioration before organ damage becomes irreversible.

Normal hemodynamic values

Arterial lines

An arterial line (A-line) placed in the radial, femoral, or brachial artery provides continuous beat-to-beat blood pressure monitoring and arterial access for ABG sampling. The waveform displays systolic, diastolic, and mean pressures. Damping (flattened waveform) indicates air, clot, or kinked tubing – troubleshoot before treating the number. Level the transducer to the phlebostatic axis (4th intercostal space, phlebostatic level at mid-chest) and zero it to atmosphere at setup, then re-level with every position change and re-zero per unit protocol or whenever readings are in doubt. Monitor the distal limb for ischemia, check the dressing per protocol, and never infuse medications through an arterial line.

Central venous catheter and CVP

A central venous catheter (CVC) in the subclavian, internal jugular, or femoral vein allows CVP measurement, vasopressor infusion, and TPN delivery. CVP reflects right atrial filling pressure, but a single CVP value is a poor predictor of fluid responsiveness; dynamic measures (pulse pressure variation, stroke volume variation, passive leg raise) are preferred for guiding fluid decisions. Low CVP (<2 mmHg) with hypotension suggests hypovolemia; elevated CVP (>12 mmHg) combined with a low CI suggests RV failure or cardiac tamponade.

Pulmonary artery catheter (Swan-Ganz)

The pulmonary artery catheter (PAC) is a flow-directed catheter advanced from a central vein through the right heart into the pulmonary artery. It directly measures CVP, PAP, and PAOP (wedge pressure), and calculates CO via thermodilution – making it the reference standard for complex hemodynamic assessment. Use in ICU has declined with the rise of less-invasive echo-based monitoring, but the PAC remains essential in refractory cardiogenic shock, post-cardiac surgery, and pulmonary hypertension management. Nursing responsibilities: monitor continuous PAP waveform, prevent catheter migration into permanent wedge position (causes infarction), and prepare for balloon inflation for wedge readings.

Mechanical ventilation

Mechanical ventilation supports or replaces a patient’s breathing work when respiratory failure prevents adequate gas exchange. ICU nurses do not independently adjust ventilator settings, but they must understand modes, alarms, and protective strategies – they are the first clinicians to identify ventilator-patient dyssynchrony, deteriorating compliance, or accidental extubation.

Ventilator modes

Key ventilator settings and lung-protective ventilation

Lung-protective ventilation (LPV) is the evidence-based standard for ARDS and is applied broadly in most mechanically ventilated ICU patients. The NHLBI ARDS Network trial (ARDSnet, 2000) demonstrated reduced mortality with lower tidal volumes – this is one of the most consequential ventilator trials in critical care history.

Core LPV parameters:

• Tidal volume (Vt): 6–8 mL/kg of ideal body weight (IBW). IBW, not actual body weight – this distinction is critical. For a 70 kg IBW patient, target Vt is 420–560 mL.
• Plateau pressure: Keep ≤30 cmH₂O (measures lung compliance; high plateau pressure = over-distension injury)
• Driving pressure: Plateau pressure minus PEEP; target <15 cmH₂O – emerging evidence suggests this is the strongest predictor of ARDS mortality
• PEEP (positive end-expiratory pressure): Maintains alveolar recruitment between breaths; typical range 5–10 cmH₂O; higher PEEP (10–20 cmH₂O) used in moderate-severe ARDS to reduce derecruitment
• FiO₂: Fraction of inspired oxygen; wean toward 0.40–0.60 to minimize oxygen toxicity; target SpO₂ 92–96% in most ARDS patients
• Respiratory rate: 12–20 breaths/min; may be higher in ARDS to maintain adequate minute ventilation at low tidal volumes

VAP bundle

Ventilator-associated pneumonia (VAP) develops in 9–27% of mechanically ventilated patients and carries substantial mortality. The current reference is the 2022 SHEA/IDSA/APIC compendium update, which prioritizes interventions that shorten ventilation over older bundle items.

VAP and ventilator-associated event prevention (SHEA/IDSA/APIC 2022 essential practices):

1. Avoid intubation when safe alternatives exist (high-flow nasal oxygen or noninvasive ventilation in selected patients)
2. Minimize sedation, favoring non-benzodiazepine agents
3. Daily spontaneous awakening trial paired with a spontaneous breathing trial
4. Early exercise and mobilization
5. Head of bed elevation 30–45°
6. Subglottic secretion drainage ETT for patients expected to need ventilation beyond 48–72 hours
7. Oral care with toothbrushing (without chlorhexidine), and change the ventilator circuit only when visibly soiled or malfunctioning

Two items from older bundles have been dropped. Chlorhexidine oral care is now generally not recommended because meta-analyses found a possible increase in mortality without a clear VAP benefit, and stress ulcer prophylaxis is still given for GI bleeding risk but does not prevent VAP.

Vasopressors and inotropes

Vasopressors restore blood pressure by increasing vascular resistance or cardiac output. ICU nurses titrate these agents continuously based on ordered MAP targets. The 2026 Surviving Sepsis Campaign guidelines recommend an initial target of 65 mmHg in septic shock, with a new conditional recommendation for a lower initial target of 60–65 mmHg in adults 65 years and older, where a meta-analysis found lower targets associated with reduced mortality. The guideline notes that holding a MAP at exactly 65 is not feasible in practice, so titrate to a reasonable range around the ordered target (roughly within 5 mmHg). Monitor for adverse effects throughout. Central venous access is preferred for prolonged or high-dose infusions, but the 2026 guidelines suggest starting vasopressors peripherally to restore MAP rather than delaying until a central line is placed. Peripheral infusion should run through a good-quality, proximal IV under a protocol with frequent site checks for extravasation.

Titration principle: use the lowest effective dose. Higher doses increase adverse effect risk without necessarily improving perfusion. Once MAP targets are achieved and the patient is hemodynamically stable, wean vasopressors gradually – typically reducing by 20–30% increments, monitoring for recurrent hypotension.

Sedation, analgesia, and delirium management

Sedation and analgesia management has shifted fundamentally over the past decade. The 2018 SCCM PADIS (Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption) guidelines establish analgesia-first, light-sedation protocols as the standard of care. Deep sedation is associated with prolonged mechanical ventilation, delirium, muscle wasting, and higher mortality.

A focused update published in March 2025 added anxiety as a new topic (renaming the framework PAADIS) and issued five further statements. Three carry direct bedside consequences for ICU nurses: use dexmedetomidine over propofol in mechanically ventilated adults where light sedation or delirium reduction is the highest priority; provide enhanced mobilization and rehabilitation over usual-care mobilization; and give melatonin over no melatonin. The panel found insufficient evidence to recommend for or against benzodiazepines specifically to treat anxiety.

RASS scale (Richmond Agitation-Sedation Scale)

The RASS quantifies sedation depth on a –5 to +4 scale. Target for most ventilated patients is light sedation, commonly RASS –2 to 0 (easily arousable), unless there is a specific indication for deeper sedation:

CAM-ICU delirium assessment

The Confusion Assessment Method for the ICU (CAM-ICU) screens for delirium in non-verbal patients. Delirium affects 60–80% of ICU patients on mechanical ventilation and is independently associated with longer ICU stays and higher 6-month mortality. CAM-ICU is positive (delirium present) when the patient has all of: (1) acute change or fluctuating mental status, AND (2) inattention, AND (3) either altered consciousness OR disorganized thinking.

Prevention strategies include early mobility (ABCDEF bundle), minimizing anticholinergic medications, maintaining sleep-wake cycles, reorientation, family presence, and hearing/vision aid availability.

Common ICU sedation and analgesic agents

Sedation vacation (daily spontaneous awakening trial, SAT): Every morning, sedation infusions are interrupted while the patient is monitored for awakening. The SAT is paired with a spontaneous breathing trial (SBT) – the SAT-SBT combination reduces time on ventilator and ICU length of stay. Restart sedation at half the prior dose if the patient shows distress, agitation, or hemodynamic instability during the SAT.

The ABCDEF bundle

The ABCDEF (ICU Liberation) bundle from the Society of Critical Care Medicine translates PADIS guidelines into six bedside-actionable elements. In the ICU Liberation Collaborative (15,226 adults in 68 ICUs), complete bundle performance was associated with lower 7-day hospital mortality, less next-day mechanical ventilation, coma, delirium, and restraint use, and roughly half the odds of ICU readmission (adjusted odds ratio 0.54).

CRRT: continuous renal replacement therapy

CRRT is used in ICU patients with acute kidney injury who cannot tolerate the rapid fluid and electrolyte shifts of conventional intermittent hemodialysis – typically due to hemodynamic instability. CRRT runs continuously at low flow rates (typically 25–35 mL/kg/h effluent dose), allowing gentle, slow solute clearance and fluid removal over 24 hours. See the AKI nursing reference for full KDIGO staging and AKI management.

When CRRT is used instead of intermittent hemodialysis:

• Hemodynamic instability (MAP <65 despite vasopressors – patient cannot tolerate rapid fluid shifts)
• Large fluid removal required (severe fluid overload in AKI Stage 3)
• Severe electrolyte and acid-base correction needed at controlled rate
• Acute liver failure with cerebral edema (CRRT controls ICP by avoiding osmotic shifts)

CRRT modalities:

• CVVH (continuous venovenous hemofiltration): solute removal by convection; replacement fluid given pre- or post-filter
• CVVHD (continuous venovenous hemodialysis): solute removal by diffusion; dialysate flows counter-current to blood
• CVVHDF (continuous venovenous hemodiafiltration): combines both; most commonly used modality

Nursing responsibilities during CRRT:

1. Access monitoring: Assess the dialysis catheter (typically large-bore dual-lumen in femoral or internal jugular vein) for kinking, position, and signs of infection every shift
2. Circuit pressure monitoring: Trend access pressure, return pressure, filter pressure, and transmembrane pressure (TMP). Rising TMP signals impending filter clotting – notify provider or initiate per protocol
3. Anticoagulation: Regional citrate anticoagulation (RCA) is now preferred over systemic heparin in most centers. With citrate, monitor ionized calcium every 4–6 hours – calcium infusions run concurrently through a separate line. Systemic ionized calcium <1.0 mmol/L requires citrate rate adjustment
4. Fluid balance: Calculate CRRT net fluid removal against the physician order every hour. Critically ill patients in CRRT are often in positive fluid balance – target net removal is explicitly ordered (e.g., –100 mL/hr)
5. Electrolyte and acid-base monitoring: Draw BMP/electrolytes every 4–6 hours. CRRT removes potassium, phosphate, and bicarbonate – replacement is added to the dialysate or replacement fluid bags as ordered. Monitor for hypophosphatemia (common in CRRT), hypokalemia, hypomagnesemia
6. Temperature: CRRT causes significant heat loss – use circuit warmer; monitor patient temperature every 2 hours; hypothermia masks fever in sepsis
7. Drug dosing: Many medications are dialyzed out by CRRT – notify pharmacy of CRRT initiation so dosing adjustments can be made (antibiotics, anticoagulants, antiepileptics)

Systematic ICU assessment: FASTHUG-S and head-to-toe

ICU nurses perform a systematic head-to-toe assessment at least every 2 hours, with continuous surveillance between assessments. Two frameworks help ensure nothing is missed.

FASTHUG-S (daily ICU care checklist)

ICU head-to-toe assessment priorities

Neurological: RASS score, GCS, pupillary response (size, reactivity, equality), CAM-ICU, pain score, limb strength, cranial nerve deficits if applicable

Cardiovascular: Heart rate, rhythm (continuous telemetry), MAP, CVP if applicable, peripheral pulses, capillary refill, skin temperature and color, edema, vasoactive drip rates

Respiratory: RR, SpO₂, ETCO₂ (if monitored), ventilator settings and alarms, breath sounds bilaterally, ETT position and cuff pressure (target 20–30 cmH₂O), sputum character and amount, suction frequency

Renal/GU: Hourly urine output (≥0.5 mL/kg/h target), urine color and character, creatinine trend, fluid balance for past 24 hours, BUN, electrolytes

GI: Bowel sounds, abdominal distension, NG/OG tube position and residual volume, stool output, signs of GI bleeding, enteral feeding tolerance

Integumentary: Pressure injury risk (Braden scale), skin integrity at all bony prominences, IV and invasive line sites (redness, drainage, dressing integrity), ETT and tube-related pressure injuries

Lines and devices: Verify all lines – type, location, date of insertion, dressing integrity, patency, necessity (remove unnecessary lines to reduce CLABSI risk)

Electrolyte monitoring in the ICU

ICU patients are at high risk for electrolyte disturbances due to organ dysfunction, diuretics, enteral feeding, CRRT, and massive fluid shifts. For a comprehensive reference, see the electrolyte imbalances reference. The table below summarizes ICU-specific intervention thresholds.

Common ICU conditions – quick reference

The site has dedicated reference pages for each of these conditions – this section provides the ICU-specific framing and links to the full content.

ARDS (acute respiratory distress syndrome): Hypoxemic respiratory failure from diffuse alveolar injury; Berlin definition (P/F ratio <300), broadened in the 2024 new global definition to include patients on high-flow nasal oxygen ≥30 L/min and SpO₂/FiO₂ ≤315 where arterial blood gases are unavailable; lung-protective ventilation is the cornerstone of management; prone positioning for P/F <150; high PEEP strategy; avoid fluid overload.

Sepsis and septic shock: Sepsis-3 definitions (organ dysfunction from infection); septic shock = MAP <65 despite fluids requiring vasopressors, plus lactate >2 mmol/L; draw blood cultures and lactate, and give at least 30 mL/kg crystalloid within the first 3 hours for sepsis-induced hypoperfusion or shock. Antimicrobial timing is split by likelihood of infection and shock status in the 2026 guidelines – immediately, ideally within 1 hour, for possible, probable, or definite septic shock and for probable or definite sepsis without shock, versus within 3 hours of first suspicion for possible sepsis without shock, after a time-limited period of rapid investigation. Screen with NEWS, NEWS2, MEWS, or SIRS rather than qSOFA alone. Norepinephrine remains first-line vasopressor.

AKI and CRRT indication: KDIGO staging; CRRT initiated at Stage 3 with hemodynamic instability; see CRRT section above for nursing management.

TBI and ICP management: ICP target <20–22 mmHg; CPP target 60–70 mmHg (CPP = MAP – ICP); head of bed 30°; avoid hypoxia (SpO₂ <90%) and hypercarbia (PaCO₂ >45); osmotic therapy with mannitol or hypertonic saline; continuous ICP monitoring via external ventricular drain (EVD) or intraparenchymal monitor.

Post-cardiac surgery ICU: Hemodynamic monitoring via PA catheter or TEE; manage coagulopathy with FFP/platelets/cryoprecipitate; chest tube output monitoring (>200 mL/hr for 2+ hours = surgical re-exploration threshold); temporary pacing wire awareness; mediastinal shift recognition (hemodynamic collapse after cardiac surgery = rule out tamponade first).

Frequently asked questions

What does an ICU nurse do?

An ICU nurse provides continuous bedside care for critically ill patients who require monitoring that cannot be safely provided on a general medical floor. Core tasks include managing mechanical ventilators, titrating vasoactive infusions to hemodynamic targets, performing hourly assessments, maintaining invasive monitoring lines, administering sedation and analgesia protocols, preventing healthcare-associated infections (VAP, CLABSI, CAUTI), implementing the ABCDEF bundle, and communicating changes in patient condition to the medical team.

How is ICU nursing different from floor nursing?

The primary differences are patient acuity, nurse-to-patient ratio, monitoring intensity, and pharmacologic complexity. ICU nurses manage 1–2 patients with continuous invasive monitoring and complex vasoactive infusions. Floor nurses manage 4–6 patients with intermittent vital signs and standard IV medications. ICU patients have little physiologic reserve – deterioration can be rapid and irreversible – so the cognitive and surveillance demands are substantially higher.

What certifications do ICU nurses need?

CCRN (Critical Care Registered Nurse), awarded by the American Association of Critical-Care Nurses (AACN), is the standard credential for adult critical care nurses. The Direct Care pathway offers two alternate routes: 1,750 hours in direct care of acutely or critically ill adult patients during the previous two years, with 875 of those hours in the most recent year preceding application; or 2,000 hours during the previous five years, with 144 hours in the most recent year. Other relevant certifications: CCRN-K for knowledge professionals in non-bedside roles, CCRN-E for tele-critical care, CMC (Cardiac Medicine Certification), CSC (Cardiac Surgery Certification), and subspecialty credentials for neonatal and pediatric critical care.

What is the ABCDEF bundle?

The ABCDEF bundle is a structured, evidence-based care protocol from the Society of Critical Care Medicine that operationalizes the PADIS guidelines at the bedside. The six elements are: Assess/prevent/manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium assessment/prevention/management; Early mobility and exercise; and Family engagement. Research in more than 15,000 ICU patients (the ICU Liberation Collaborative) found that higher bundle compliance reduces mortality, delirium days, and mechanical ventilation duration.

What is lung-protective ventilation?

Lung-protective ventilation (LPV) limits ventilator-induced lung injury by using low tidal volumes (6–8 mL/kg IBW), targeting plateau pressures ≤30 cmH₂O, and applying appropriate PEEP to maintain alveolar recruitment. The NHLBI ARDSnet trial established 6 mL/kg IBW tidal volumes as the standard in ARDS, reducing 28-day mortality from 39.8% to 31.0% versus 12 mL/kg conventional ventilation.

What is a Swan-Ganz catheter used for?

A Swan-Ganz (pulmonary artery) catheter provides direct measurement of CVP, pulmonary artery pressures, and pulmonary artery occlusion pressure (wedge pressure), along with thermodilution cardiac output. It allows differentiation of cardiogenic from non-cardiogenic pulmonary edema (PAOP >18 mmHg suggests cardiogenic etiology) and guides vasopressor and inotrope therapy in complex shock states. Its use has declined with advances in echocardiography, but it remains valuable in refractory shock and post-cardiac surgery patients.

Clinical content reviewed against AACN critical care nursing standards, SCCM PADIS guidelines (2018, with the 2025 focused update), NHLBI ARDSnet tidal volume protocol, Surviving Sepsis Campaign 2026 guidelines, and NIH/NCBI StatPearls vasopressor and inotrope reference (NBK482411). This reference is for educational purposes and does not substitute for institutional protocols or clinical judgment.

References

1. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287

2. ARDS Definition Task Force; Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526–2533. doi:10.1001/jama.2012.5669

3. Prescott HC, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2026. Crit Care Med. 2026;54(4):725–812. doi:10.1097/CCM.0000000000007075 (co-published in Intensive Care Med. 2026;52(5):863–936. doi:10.1007/s00134-026-08361-1)

4. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825–e873. doi:10.1097/CCM.0000000000003299

5. Lewis K, Balas MC, Stollings JL, et al. A focused update to the clinical practice guidelines for the prevention and management of pain, anxiety, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2025;53(3):e711–e727. doi:10.1097/CCM.0000000000006574

6. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107–1116. doi:10.1056/NEJMoa1005372

7. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–2168. doi:10.1056/NEJMoa1214103

8. Combes A, Hajage D, Capellier G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018;378(21):1965–1975. doi:10.1056/NEJMoa1800385

9. Brower RG, Matthay MA, Morris A, et al; Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–1308. doi:10.1056/NEJM200005043421801

10. Yealy DM, Kellum JA, Huang DT, et al; ProCESS Investigators. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683–1693. doi:10.1056/NEJMoa1401602

11. Peake SL, Delaney A, Bailey M, et al; ARISE Investigators; ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2014;371(16):1496–1506. doi:10.1056/NEJMoa1404380

12. Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care. 2011;17(1):43–49. doi:10.1097/MCC.0b013e3283427243

13. Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014;42(5):1024–1036. doi:10.1097/CCM.0000000000000129

14. Ely EW, Shintani A, Truman B, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291(14):1753–1762. doi:10.1001/jama.291.14.1753

15. American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA: AACN; 2016.

16. Surviving Sepsis Campaign; Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165–228. doi:10.1007/s00134-012-2769-8 (historical; superseded by the 2016, 2021 and 2026 editions, see reference 3)

17. Matthay MA, Arabi Y, Arroliga AC, et al. A new global definition of acute respiratory distress syndrome. Am J Respir Crit Care Med. 2024;209(1):37–47. doi:10.1164/rccm.202303-0558WS

18. Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43(6):687–713. doi:10.1017/ice.2022.88