Dear Dr. Misganaw,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 18 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Dereje Zewdu Assefa, BSc, MSc

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please amend the manuscript submission data (via Edit Submission) to include author Eniyew Fenta.

3. Please amend your authorship list in your manuscript file to include author Enyew Fenta Mengistu.

4. Please remove your figures from within your manuscript file, leaving only the individual TIFF/EPS image files, uploaded separately. These will be automatically included in the reviewers’ PDF.

5. We are unable to open your Supporting Information file [PACU complication.sav final.sav]. Please kindly revise as necessary and re-upload.

6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information .

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments:

The abstract section does not need to include a separate "Objective" heading, as the objective is already part of the background. Please revise and proofread the entire manuscript carefully, as there are numerous grammatical errors and typographical issues. Ensure consistency in terminology, especially regarding the use of "overweight" and "obesity," and avoid casual or interchangeable language.

Instead of stating, “Today, surgical procedures are accepted as one of the most important therapeutic methods in all societies worldwide,” consider rephrasing to: “Nowadays, surgical procedures are widely recognized as essential therapeutic interventions across all societies.”

Avoid redundancy and unnecessary detail. For example, the following sentence should be revised for clarity and brevity:

“A post-anesthesia care unit, often abbreviated as PACU and sometimes referred to as post-anesthesia recovery (PAR), is a vital part of hospitals. It is an area, normally attached to operating room suites, designed to provide care for patients recovering from general anesthesia, regional anesthesia, or local anesthesia.”

This should be simplified and written more precisely.

Remove the separate headings for “General” and “Specific Objectives” and instead integrate the study aim into the final paragraph of the introduction. Please refer to the PLOS ONE journal format and review previously published articles to guide your revisions.

The “Methods and Materials” section requires substantial language editing. For example, the sentence:

“Patients who were transferred directly from the operation room to an intensive care unit or ward excluded in the study,”

should be rephrased and justified, as major surgical procedures are often followed by direct transfer to ICU or ward, which may influence the incidence of critical events.

Although the authors state that a 50% prevalence was used due to the lack of similar studies in Ethiopia, there is in fact a related study with comparable findings. Please revise the justification accordingly.

Explain why seven data collectors and six supervisors were involved, as this may introduce variability and bias. Revise the data collection section to improve clarity and eliminate ambiguity.

Clarify why the pre-test was conducted at the same institution where the study took place.

The terminology regarding outcomes is inconsistent. Terms such as “PACU complications,” “critical events,” and “critical incidents” are used interchangeably. Please choose a single term and use it consistently throughout the manuscript.

In the study population, clarify the age range included. If the study spans a wide range (e.g., 3 to 86 years), consider whether this is clinically appropriate, given that complication rates and types likely differ across age groups.

Clarify whether your source population includes all surgical patients or only those undergoing major surgery. Also, assess whether including procedures performed under sedation in both major and minor ORs introduces clinical heterogeneity.

Table 2 needs revision, as some values (e.g., total sum of critical events by ASA class) exceed 100%. Verify and correct the data presentation.

Patients undergoing general, regional, or sedative anesthesia represent clinically distinct groups. Consider whether it is appropriate to analyze them together when measuring the incidence of postoperative critical events.

Further comments on the results and discussion sections will follow once the above major issues have been addressed.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Abstract; methodology (rephrase)

Background; paragraph 2:On the other hand, delayed effects of different anesthetic agents and muscle relaxants affects negatively the natural ability of the body to maintain physiological balance, which finally causes post-anesthetic critical incidents (critical events). (cite/ find reference)

last paragraph: Therefore the finding of this study will contribute in minimizing the doubt regarding the type of factors and common post-operative critical incidents. (rephrase)

Methodology; data collection; (rephrase)

Results: repeated several times in the text

Discussion: More of literature review. Discuss why did you get the results. Highlight the limitations and explain why eg: 2 hour delay, Improper passing over etc.

Reviewer #2: Well done. I love your research & how it was done. However, there are a couple issues I have with your work.

There are a lot of grammatical errors and poorly constructed sentences, especially in the abstract and background sections. Also, your work did not include If day cases or people already on admission had an effect on critical events in PACU.

Besides, I'd have loved it personally if the chart at the end of the work is brought into the result section. I'll have also loved if discharge scoring systems in PACU were examined in relation to critical incidence.

Reviewer #3: Reviewer Report for Manuscript PONE-D-25-27675

Summary :

This prospective study on PACU complications in a resource-limited Ethiopian hospital addresses a significant knowledge gap. While the topic is important and the design has strengths, major methodological, statistical, and reporting flaws preclude acceptance. Extensive revisions and re-analysis are essential.

Major Concerns :

1. Methodological Rigor :

- Sample size calculation using 50% prevalence lacks justification. Recalculate using literature-based estimates (e.g., 20-35%) and perform post-hoc power analysis.

- Critical event definitions are inconsistent and unvalidated (e.g., SpO₂<90% for >3 minutes; Clavien-Dindo applied to PACU without validation). Standardize terminology ("critical events" vs. "complications") and align with WHO/ANZCA guidelines. Report inter-rater reliability (κ-statistic).

- Data collection gaps : No standardized discharge criteria (e.g., Aldrete score), and missing data strategy unreported. Address "na" entries in complication timing/type (13% of events).

2. Statistical Validity :

- Regression models are inadequately developed :

- Age retained despite non-significance (p=0.31); no justification for variable inclusion.

- Multicollinearity unchecked (e.g., ASA-BMI-duration correlation likely).

- Full bivariable results omitted; sensitivity analyses missing.

- Incorrect incidence reporting :

- Cardiovascular events: 42% of *events* reported without *patient-level* incidence (21.3% of patients).

- Table 2 mislabels subgroup *incidence* (e.g., 69.5% in ≥65yrs) as "proportions," lacking 95% CIs.

- Data quality issues :

- Pediatric patients categorized with adult BMI.

- Inconsistent coding ("femal," "secere," variable "na" rates).

3. Reporting & Interpretation :

- Results :

- No CONSORT diagram for patient inclusion.

- Table 5: Wide CI for ASA4 (AOR=11.75, 95%CI:2.76-50.03) suggests instability; unaddressed.

- Discussion :

- Poor contextualization of high complication rates (37.9%) within resource limitations (e.g., 54.4% complications without nurse training).

- War-related caseload reduction ignored in generalizability.

- Limitations : Single-center design, observer bias, and selection bias (ICU-excluded patients) inadequately discussed.

Essential Revisions :

1. Statistical Re-analysis :

- Report patient-level incidence with 95% CIs for *all* complications (e.g., "21.3% [17.5–25.7%] of patients had cardiovascular events").

- Re-run regressions: Provide full bivariable results, check multicollinearity (VIF), validate models (ROC-AUC), and conduct sensitivity analyses.

- Post-hoc power analysis for key outcomes.

2. Methodological Corrections :

- Correct pediatric BMI categorization.

- Define missing data handling (e.g., "Multiple imputation used for 13.1% missing complication timings").

- Justify event definitions and validate Clavien-Dindo for PACU.

3. Reporting Compliance :

- Add 95% CIs to *every* incidence rate (Abstract, Results, Tables 2–5).

- Relabel Table 2: " Incidence of critical events, % (95% CI) " with footnote: "*% of subgroup patients with ≥1 event*."

- Ethical committee pproval number and data repository/access details (PLOS ONE requirement).

4. Contextual Enhancement :

- Discuss war impact on caseload/complications.

- Contrast findings with LMIC studies.

- Propose actionable interventions (e.g., nurse training program budget impact).

Long-term Recommendations :

- Multi-center validation.

- Standardized PACU discharge protocol development.

- Risk prediction model refinement.

Conclusion :

While this study highlights critical PACU safety challenges in resource-limited settings, methodological flaws and statistical misreporting undermine its contribution. I recommend partnering with a biostatistician to address these concerns. *Major revision is required before reconsideration*.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Huda Zainal Abidin

Reviewer #2: Yes: Adefusi Temiloluwa Oluwakorede

Reviewer #3: Yes: Ali Afkhaminia

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Dear Dr. Misganaw,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 27 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Dereje Zewdu Assefa, BSc, MSc

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments:

In the abstract section

In methods of abstract section please revise it in this way “An institution-based prospective cross-sectional study was conducted from June 1, 2024, to September 30, 2024.” Revise as follows “Analysis was conducted using bivariable and multivariable logistic regression as needed.”

In the results section, you stated that "Out of 422 operations, 37.9% of patients developed about 214 complications." Please consider rephrasing this statement for clarity.

In the conclusion, revise as follows: “Patients who had intraoperative complications, higher ASA status, unhealthy body weight, and those who received anesthesia for a prolonged duration were relatively at higher risk of developing critical events.” Please replace the term "unhealthy body weight" with the appropriate term using BMI.

Change the heading title from "Background" to "Introduction" at the end of the abstract; it should begin as "Introduction," not "Background."

In the introduction section, please include references that support the evidence you are using as much as possible. I've noticed that some statements have only one or two citations, despite being quite broad.

The language and grammar have been significantly improved; however, it still needs revision. Please read it carefully line by line and use appropriate transition terms to connect each statement throughout the entire document.

Revise as stated “In developing countries, including Ethiopia, most PACU setups do not meet WHO standards, and some hospitals lack a PACU altogether, sending patients directly from the operating room to the ward.”

You mentioned that "Although several studies have been published on complications in the PACU, there is limited information in Africa." However, you need to provide a reference for this statement.

Please refrain from providing detailed lists of independent and dependent variables. Instead, use statements to describe them.

Please provide details on how the data were transitioned from bivariate to multivariate analysis, as well as how multicollinearity was assessed in the data analysis section.

Please provide details in the limitations section. For example, various types of surgical procedures and significant critical event types were assessed, and a wide range of age groups was included. It is recommended that specific research focusing on particular types of surgery be conducted.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

Reviewer #3: Yes

**********

Reviewer #2: This research topic is very interesting and important also. I'm also happy with the improvement in the review of the article as compared to the initial draft, especially as regards grammar and construct. I appreciate the correlations between critical incidents and ASA classification, trained personnel, BMI and other criteria. I also appreciate the "Recommendation" section because the article did outline the need for a proper PACU handover criteria and training of PACU personnel to help with prevention and management of complications.

However, I'll like to query the choice of words and terminologies such as Tachyarrythmia and Bradyarrythmia over tachycardia and bradycardia. Hypertension with Systolic Blood Pressure >180mmHg is according to what criteria?

When patients were finally discharged from PACU, what discharge criteria was used?

Besides, your study did not account for any difference in critical incidence between Day cases and in patients, if there are any.

Lastly, a few grammar and construct adjustments could be made to perfect the article. Nonetheless, it's a work well done!

Reviewer #3: General Comments

This is an important prospective study addressing perioperative safety in a resource-limited setting. The topic is highly relevant, particularly given the paucity of data on PACU outcomes in sub-Saharan Africa. The revised version has improved substantially; however, there remain issues in clarity, structure, reporting, and methodological detail that should be addressed before acceptance. Below, I provide detailed comments for the authors and editorial team.

Major Concerns

Abstract

The sentence “A P-value <0.05 was considered statistically significant” should be removed from the abstract; such technical details belong in the Methods.

The conclusion is vague: “A significant number of patients suffered…”. Please quantify (“Approximately 38% of patients experienced ≥1 critical event, mainly cardiovascular and respiratory complications.”).

Background

The abbreviation ASA is used without definition. Please spell out in full at first mention (American Society of Anesthesiologists physical status classification), then abbreviate.

Methods

Independent/Dependent Variables: These are listed as bullet points (p. 5). For PLOS ONE style, rephrase into sentences/paragraphs (e.g., “Independent variables included age, sex, ASA status, BMI, type of anesthesia…”).

Statistical Model Fit: The manuscript mentions Omnibus and Hosmer–Lemeshow tests but does not explain them. Please describe their purpose and null hypotheses (Omnibus: H₀ = no predictors improve the model; Hosmer–Lemeshow: H₀ = model fits observed data). Interpret the reported p-values (e.g., p=0.085 indicates no evidence of poor fit).

Adjustment Strategy: Clarify that only variables with p<0.20 in bivariable analysis were retained for multivariable regression, and state explicitly that other covariates were excluded.

Ethics: The ethics section mentions approval but no code/number. Please provide the approval code, or explicitly state that the committee did not issue one.

Clavien–Dindo Grades: Consider a separate regression analysis restricted to Grade III–V complications to identify predictors of severe, life-threatening events.

Results – Tables

Table 2–4: The column header “Proportion of critical events in subgroups” should be replaced with “Incidence of critical events (% with ≥1 event, 95% CI)”. Confidence intervals should be added.

Narrative Clarity: Avoid vague terms like “nearly equal” (p. 11); report actual numbers/percentages.

Event Reporting: For each complication (hypotension, shock, arrhythmia, etc.), present both counts and percentages (e.g., “41 cases of hypotension, 19.2%”).

Nurse Training Comparison: Where differences are noted (trained vs. untrained), present percentages and statistical results (p-values/AOR) in the text, not only in tables.

Table 5:

Add a column for p-values corresponding to CORs.

Clarify which covariates were included in AOR adjustment.

Figures – Flow Diagram

The boxes require alignment correction for readability.

Excluded patients are not quantified. Please add the total n of excluded patients with reasons.

The n = 422 included label should be placed adjacent to “Patients included in the study,” not before.

The final node should branch into two groups: “Patients with ≥1 critical event (n = …)” and “Patients without critical events (n = …)”. This would better communicate study outcomes.

Limitations

The limitations section should note that the study only assessed immediate PACU complications and could not capture delayed but clinically important events such as pulmonary thromboembolism (PTE). Acknowledge that this is a serious limitation of the PACU-only timeframe.

Minor Concerns

Replace the phrase “post-anesthesia complications also known as critical incidents” with more consistent terminology (“critical events”) throughout.

Ensure that percentages are consistently reported alongside raw numbers across Results and Discussion.

Revise wording such as “nearly equal” or “not surprising” with precise, scientific expressions.

Flow and grammar should be further polished (e.g., “a P-value <0.05 was consider” → “considered”).

Conclusion

This manuscript addresses an under-researched but highly important area of perioperative safety in low-resource settings. However, improvements are needed in reporting clarity, statistical transparency, and figure/table presentation. Addressing the above concerns—particularly the Abstract, Results tables, flow diagram, and model explanation—will substantially strengthen the manuscript and make it more suitable for publication.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2: No

Reviewer #3: Yes: Ali Afkhaminia

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Dear Dr. Misganaw,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Feb 05 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Dereje Zewdu Assefa, BSc, MSc

Academic Editor

PLOS One

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

The abstract should be short and precise. Please revise the background section of your abstract as follows: ‘Surgery and anaesthesia can disrupt normal physiological function through surgical stress and residual anaesthetic effects, increasing the risk of post-anaesthetic complications, known as critical incidents. This study aimed to determine the incidence of critical events in the post-anaesthesia care unit at Debre Markos Comprehensive Specialized Hospital, Ethiopia.”

On the results of the abstract section, please provide OR (odds ratio) of associated factors.

In the conclusion section, you have mentioned that ASA status was associated with the risk of developing critical events. Please be specific about which group of ASA status is associated with complications.

In the conclusion, it is better to mention under/overweight instead of describing them separately.

In the introduction section, you don’t need to provide a dearth of information; please be specific to your study and avoid repetition, and try to summarise long statements.

In the methods section, instead of using the study variable sub-heading, change it to the study outcomes and write it as follows:

The main outcome measure was critical events in the PACU, which was defined as… the point mentioned in the operational definitions, and delete the statement included in the operational definitions of critical outcomes. Then, include the secondary outcomes accordingly.

Rewrite your limitations and strengths section as follows: This study's strength lies in its prospective design, which allowed for the comprehensive recording of all complications that occurred during recovery. In contrast, a retrospective study design may overlook critical events or make them difficult to recall. However, a limitation of this study is that it assessed various types of surgical procedures and significant critical event types while encompassing a wide range of age groups. Therefore, it is recommended that further research focus on specific types of surgery. This study was limited to evaluating immediate postoperative complications occurring in the PACU and did not consider delayed yet clinically significant events, such as pulmonary thromboembolism (PTE). Additionally, as this study was conducted at a single institution, conducting research in a multicentre setting with a larger sample size would be beneficial.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #3: Yes

**********

Reviewer #3: . Abstract:

Result: Clarify the first sentence for precision. Instead of "Out of 422 patients, 37.9% of patients developed about 214 complications," consider:

"Of the 422 patients, 160 (37.9%) experienced one or more critical events, with a total of 214 complications recorded."

Conclusion: Ensure consistency. The phrase "unhealthy body weight" in the conclusion should be explicitly tied to the BMI categories used (overweight/underweight).

2. Introduction:

Flow: Improve connectivity between sentences. Use transition words (e.g., Furthermore, Consequently, However) to guide the reader through the rationale.

Citations: Verify that the statement about limited data in Africa is directly supported by the newly added references (e.g., Blaise Pascal FN et al. 2021).

3. Methods:

Ethics: The approval code R/C/S/D/357/01/18 is now included, which is good.

Clarity: The explanation for not analyzing Clavien-Dindo Grade III-V separately (sample size limitations) is acceptable but should be stated clearly in the limitations section if not already.

4. Results:

Language: Replace informal phrases. For example:

"Even though it’s not surprising..." → "As anticipated, the incidence..."

"The proportions... were nearly equal..." → "The proportions were similar across groups, ranging from 35% to 38.4%."

Narrative: When discussing Table 5 in the text, explicitly state the key findings (e.g., "Patients attended by untrained nurses had over three times the odds of experiencing a critical event (AOR=3.15...).")

5. Discussion:

Tone: Maintain an objective, scientific tone. Avoid speculative phrasing like "We couldn’t provide the possible reasons..." Instead, state: "The reason for this discrepancy is not clear from our data but may relate to differences in case mix or definitions."

Structure: When comparing studies, first state the agreement or disagreement, then provide the comparative data, and finally offer a brief, plausible reason for the difference.

6. Language & Grammar (Final Polish):

Conduct a meticulous line-by-line edit focusing on:

Article Use: Ensure correct use of "a," "an," and "the."

Prepositions: Check "in," "on," "at," "for," etc.

Subject-Verb Agreement: (e.g., "The data were analyzed").

Plurals: (e.g., "complications").

Typos: "Sever hypoxemia" → "Severe hypoxemia"; "statistically significant" (not "statically").

7. Figures & Tables:

Flowchart (Figure 1): Ensure it matches the description in the "Response to Reviewers":

Quantify excluded patients (n=11).

Place "n = 422" label next to "Patients included in the study".

Final branch clearly shows: "Patients with ≥1 critical event (n=160)" and "Patients without critical events (n=262)".

Submission Checklist:

Before final submission, verify:

The Response to Reviewers letter is complete, polite, and addresses every point raised by each reviewer and the editor.

The Data Availability Statement in the submission system is accurate.

All supporting files (dataset, checklist, ethical approval) are uploaded.

The manuscript text is the "clean" version with all track changes accepted and no comment bubbles.

Conclusion

The manuscript is in its final stages. By implementing these focused revisions for clarity, precision, and language polish, you will significantly strengthen it for publication. The study provides valuable, actionable insights for improving PACU care in similar resource-limited settings.

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Reviewer #3: Yes: Ali Afkhaminia

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Dear Dr. Misganaw,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 03 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Dereje Zewdu Assefa, BSc, MSc

Academic Editor

PLOS One

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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Please change the title "Incidence of Critical Events in the Post-Anaesthesia Care Unit at a Resource-Limited Setting in Debre Markos, Northwest Ethiopia" to lower case. Additionally, please proofread for any typos once again.

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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Incidence of Critical Events in the Post-Anesthesia Care Unit at a Resource-Limited Setting in Debre Markos, Northwest Ethiopia

PONE-D-25-27675R4

Dear Dr. Misganaw,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Dereje Zewdu Assefa, BSc, MSc

Academic Editor

PLOS One

Additional Editor Comments (optional):

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