Type of infections in the critically ill

Infections in intensive care unit (ICU) patients are discussed from the perspective of three recent studies performed in different critical care settings, namely a general/cardiac paediatric ICU, a mixed medical/surgical adult ICU and a neonatal surgical unit. Definitions are given for the diagnosis of infection in various body sites.The common infections, which occurred in these ICU patients, are described, with the main problems being in blood and lower airways. Infections are also classified epidemiologically and in terms of pathogenicity. All three studies used the concept of the carrier state to evaluate the epidemiology of the infections. The commonest cause of infection was with microorganisms carried by the patient on admission. Infections caused by organisms acquired after admission are of a lower magnitude but considerable importance. The value of surveillance cultures in classifying infections and in instituting treatment, isolation and prevention policies is illustrated by the findings of these studies.     

Immediate and 5-year cumulative outcome after paediatric intensive care in Sweden

Background: Little has been reported about intensive care of children in Sweden. The aims of this study are to (I) assess the number of admissions, types of diagnoses and length-of-stay (LOS) for all Swedish children admitted to intensive care during the years 1998–2001, and compare paediatric intensive care units (PICUs) with other intensive care units (adult ICUs) (II) assess immediate (ICU) and cumulative 5-year mortality and (III) determine the actual consumption of paediatric intensive care for the defined age group in Sweden.
Methods: Children between 6 months and 16 years of age admitted to intensive care in Sweden were included in a national multicentre, ambidirectional cohort study. In PICUs, data were also collected for infants aged 1–6 months. Survival data were retrieved from the National Files of Registration, 5 years after admission.
Results: Eight-thousand sixty-three admissions for a total of 6661 patients were identified, corresponding to an admission rate of 1.59/1000 children per year. Median LOS was 1 day. ICU mortality was 2.1% and cumulative 5-year mortality rate was 5.6%. Forty-four per cent of all admissions were to a PICU.
Conclusions: This study has shown that Sweden has a low immediate ICU mortality, similar in adult ICU and PICU. Patients discharged alive from an ICU had a 20-fold increased mortality risk, compared with a control cohort for the 5-year period. Less than half of the paediatric patients admitted for intensive care in Sweden were cared for in a PICU. Studies are needed to evaluate whether a centralization of paediatric intensive care in Sweden would be beneficial to the paediatric population.     

Intraossärer Zugang beim innerklinischen Notfall

Since the release of the 2005 resuscitation guidelines intraosseous infusion has been recognized as the favorite alternative vascular access in emergency patients. It is no longer restricted to paediatric emergencies but is also considered the vascular access of choice for adult patients with difficult venous access. Intraosseous access has been used in an increasing proportion of patients especially in an out-of-hospital emergency care setting while only limited experience exists for in-hospital usage of this technique. This article reports on a case of intraosseous access performed in a critically ill patient directly after admission to the intensive care unit (ICU) due to difficult peripheral venous access. Despite the extensive medical resources available in the ICU (i.e. central venous catheterization) less invasive means were used to render appropriate care. Based on this case different strategies of critical care and possible improvements will be discussed. Intraosseous infusion should be regarded as an infrequently needed but potentially life-saving procedure that is still too often considered as an option at later stages during in-hospital emergency care.     

Home care for chronic respiratory failure in children: 15 years experience

BACKGROUND: Advances in paediatric intensive care have reduced mortality but, unfortunately, one of the consequences is an increase in the number of patients with chronic diseases. It is generally agreed that home care of children requiring ventilatory support improves their outcomes and results in cost saving for the National Health Service. METHODS: Since 1985, the Children's Hospital Bambino Gesù of Rome has developed a program of paediatric home care. The program is performed by a committed Home Health Care Team (HHCT) which selects the eligible patients for home care and trains the families to treat their child. During the period January 1985 to January 2001, 53 children with chronic respiratory failure were included in the home care program. Of these, seven patients were successively excluded and six died in our intensive care unit (ICU), while one still lives in our ICU since 1997. The results obtained in the remaining 46 children are reported. RESULTS: The pathologies consisted of disorders of respiratory control related to brain damage (26%), upper airways obstructive disease (26%), spinal muscular atrophy (22%), myopathies and muscular dystrophies (6.5%), bronchopulmonary dysplasia (6.5%), tracheomalacia (6.5%), central hypoventilation syndrome (4.3%) and progressive congenital scoliosis (2.2%). Of these 46 patients, 34 children are mechanically ventilated and the median of their ICU stay was 109.5 days (range 54-214 days), while the remaining 12 children were breathing spontaneously and the median of their ICU stay was 90.5 days (range 61-134 days). We temporarily readmitted six patients to our ICU to perform scheduled otolaryngological surgery, eight patients for acute respiratory infections and two patients for deterioration of their neurological status due to high pressure hydrocephalus for placement of a ventriculoperitoneal shunt; these 16 patients were discharged back home again. Two other patients were readmitted for deterioration of their chronic disease and died in our ICU, while seven patients died at home. CONCLUSIONS: Thirty-seven children are still alive at home and four of them improved their respiratory condition so that it was possible to remove the tracheostomy tube. Our oldest patient has now achieved 15 years of mechanical ventilation at home.     

Acute renal failure in medical and surgical intensive care units--a one year prospective study

The spectrum of acute renal failure is different in intensive care unit (ICU) vs. non-ICU population. This one year prospective study carried out in medical and surgical intensive care units showed an incidence of 8.6% of acute renal failure. The incidence of acute renal failure was highest in medical ICU (17.2%) followed by burns ICU (5.3%), pulmonary ICU (5.2%), stroke ICU (4.4%), surgical ICU (3.1%) and least in coronary ICU (1.3%). The acute renal failure was attributable to medical causes in 68% followed by surgery and trauma in 21.2%, burns in 5.6% and pregnancy related in 5.1%. In majority, acute renal failure was multifactorial. Septicemia was the commonest cause in both medical (50%) and surgical (86%) ICUs. Multi organ system failure was present in 77.3% of patients with acute renal failure. Approximately 40% required dialysis. The mortality of acute renal failure was 62% and the mortality was correlated with the number of organ system failures, presence of oliguria and septicemia. The mean ICU stay was significantly shorter in the non-survivors.     

Acute Renal Failure in Medical and Surgical Intensive Care Units—A One Year Prospective Study

The spectrum of acute renal failure is different in intensive care unit (ICU) vs. non-ICU population. This one year prospective study carried out in medical and surgical intensive care units showed an incidence of 8.6% of acute renal failure. The incidence of acute renal failure was highest in medical ICU (17.2%) followed by burns ICU (5.3%), pulmonary ICU (5.2%), stroke ICU (4.4%), surgical ICU (3.1%) and least in coronary ICU (1.3%). The acute renal failure was attributable to medical causes in 68% followed by surgery and trauma in 21.2%, burns in 5.6% and pregnancy related in 5.1%. In majority, acute renal failure was multifactorial. Septicemia was the commonest cause in both medical (50%) and surgical (86%) ICUs. Multi organ system failure was present in 77.3% of patients with acute renal failure. Approximately 40% required dialysis. The mortality of acute renal failure was 62% and the mortality was correlated with the number of organ system failures, presence of oliguria and septicemia. The mean ICU stay was significantly shorter in the non-survivors.     

Demography of paediatric renal care in Europe: organization and delivery.

BACKGROUND: Members of the European Society of Paediatric Nephrology (ESPN) initiated a study of the demography and policy of paediatric renal care among European countries at the end of the 20th century. METHODS: A questionnaire was mailed to the presidents of each of 43 national renal paediatric societies or working groups in Europe. Data on each country's population, income as reflected by its gross national product and infant mortality rate, were obtained from the United Nations. The paediatric health care systems were previously divided into three types: general practitioner care system, paediatric care system and combined care system (CCS). RESULTS: In 1998, 842 specialized paediatric nephrologists worked in hospitals in 42 European countries. The median number of paediatric nephrologists per million child population (pmcp) was 4.9 (range 0-15). The median number of children served per paediatric nephrologist was significantly higher in countries with the general practitioner care system than in those with the paediatric or combined care system (CCS), namely 370 747 vs 169 456 and 191 788, respectively. In addition to specially trained paediatric nephrologists, there were 1087 paediatricians with a part-time interest/activity in paediatric nephrology in hospitals in 34 European countries. Eastern European countries had significantly more general paediatricians with part-time nephrological activities than countries belonging to the European Union (EU), 16.7 vs 6.6 pmcp. In 1998, 92% of 42 European countries offered paediatric dialysis facilities for acute renal failure and 90% for chronic renal failure and 55% offered paediatric renal transplantation (RTx). Only 30% of Eastern European countries (central omitted) offered paediatric RTx vs 87% of EU countries. The availability of paediatric RTx was associated significantly with the countries' gross national product (r = 0.53, P<0.001). The median number of paediatric hospitals offering dialysis for childhood chronic renal failure was 1.5 pmcp (range 0-5.0) and the median number of paediatric hospitals offering paediatric RTx was 0.4 pmcp (range 0-3.5). Fewer children were on dialysis or were transplanted in Eastern European countries than in the EU. CONCLUSIONS: At the end of the 20th century, there was a marked variation in delivery of paediatric renal care within Europe. This was related to factors such as size of the population, geographical and political situation, the type of primary paediatric care system and economic situation. European countries were far from equal with regard to access of renal replacement therapy for children. Improvement of the economic situation is beyond the capabilities of paediatric nephrologists. However, in these days of world-wide globalization paediatricians in greater Europe should be able to achieve better cooperation and exchange of ideas and information which would be the first step towards equality of renal care for children.     

Aspects of Brazilian paediatric nephrology

Brazil is a large country with different population densities in its five geographical regions, each of which has severe but unevenly distributed socioeconomic problems which affect the health care system. This makes the accurate assessment of renal disease in the large paediatric population which comprises 40% of the total population especially difficult. This paper analyses the experience of one paediatric nephrology unit. Urinary tract infection affecting 44% of the patients was the most common disease. There was a high incidence of vesicoureteric reflux and renal scarring. The proportion of poststreptococcal glomerulonephritis did not exceed 11% whilst nephrotic syndrome in its various forms represented 20% of the patients. End-stage renal failure was common and difficult to manage. Renal transplantation could not meet the demand for a variety of reasons, thus there has been an alarming annual increase in the number of patients on dialysis. Other disease encountered in smaller numbers included acute renal failure, other glomerulopathies (mainly IgA), tubulopathies and renal lithiasis.     

Technology Insight: treatment of renal failure in the intensive care unit with extended dialysis

Sustained low-efficiency dialysis (SLED) is an increasingly popular extracorporeal renal replacement therapy for patients with renal failure in the intensive care unit (ICU). Several centers across the world employ this 'hybrid' technique, which has advantages of both intermittent and continuous methods. The goal of these centers is to provide an easy-to-perform treatment with reduced solute clearances for prolonged periods. Many centers use standard, sophisticated dialysis equipment for SLED. An increasing number of hospitals in Europe and South America employ a single-pass batch dialysis system, the procedural simplicity of which makes it an ideal modality for SLED in the ICU. All systems offer the advantages of flexible timing of treatment and reduced costs; their ease of handling means that SLED is readily accepted by ICU staff. Prospective controlled studies have shown that SLED clears small solutes with an efficacy comparable to that of intermittent hemodialysis and continuous venovenous hemofiltration (even when the latter employs high rates of fluid substitution). Cardiovascular tolerability associated with SLED is similar to that associated with continuous renal replacement therapy, even in severely ill patients. Nocturnal dialysis -- a special form of SLED -- has all the advantages outlined above, with the added benefit of unrestricted physician access to the patient during the day, minimizing the interference of renal replacement therapy with other ICU activities.     

Postoperative Care in Kidney Transplantation: A Comparison Between Controlled and Uncontrolled Donation After Circulatory Death

Recent research in kidney transplantation has revealed differences in the evolution of renal function among patients transplanted from 2 alternative programs for donation after circulatory death (DCD). A retrospective, observational, single-center study was carried out from 2013 to 2016 at a level III hospital intensive care unit (ICU) to assess the progression of kidney recipients after transplants from uncontrolled DCD (uDCD) or controlled DCD (cDCD). The following variables were collected for data analysis: demographics, comorbidities, type of donation, lactate, hemoglobin and glucose levels at ICU admission, creatinine concentration at ICU admission, at-hospital ward transfer, at-hospital discharge, radioisotope imaging results, ICU and in-hospital length of stay, and mortality. There were 87 patients eligible for analysis, 42.5% of which were uDCD recipients. Improvement in kidney function was significantly delayed after uDCD compared with cDCD. A multivariate analysis showed that both uDCD and lactate levels at ICU admission increase the risk of poor outcome after renal transplantation. No deaths were registered in either patient group. Our results suggest that kidney transplantation recipients from uDCD recover renal function at a slower rate than patients transplanted from cDCD, a factor that does not affect mortality.     

The Outcomes of Critically Ill Patients with Combined Severe Acute Liver and Kidney Injury Secondary to Paracetamol Toxicity Requiring Renal Replacement Therapy

Abstract

There is a paucity of outcome data for critically ill patients with combined acute liver and kidney injury secondary to paracetamol overdose (POD) requiring renal replacement therapy (RRT). We retrospectively reviewed all admissions over a 6-year period to the intensive care unit (ICU) at a university teaching hospital which supports an active liver transplant program. Of the 5582 admissions over this period, 73 patients were admitted with combined liver and kidney injury requiring RRT, and of these 10 patients went on to receive a liver transplant. Overall mortality was 58%, being lower at 20% for transplant recipients. Transplant recipients were younger than non-transplanted patients with similar global disease severity scores [Model for End-Stage Liver Disease (MELD) and Acute Physiology and Chronic Health Evaluation II (APACHE II)]. Patients with a higher MELD or APACHE II score fared worse and patients fulfilling the King’s College Hospital transplant criteria on admission had an odds ratio (OR) for death of 3.8 (1.3–10.6). Logistic regression modeling found that only a higher admission bilirubin OR 1.6 (1.1–2.3) mg/dL and a lower creatinine OR 0.52 (0.3–0.9) mg/dL were predictive of mortality. Of the ICU survivors, 41% remained RRT dependant at the time of ICU discharge; all regained independent renal function by 1 month. Combined severe acute liver and kidney injury secondary to POD requiring RRT is associated with a high mortality. The majority of survivors recover independent kidney function by 1 month. Standard disease severity scores appear to reflect prognosis in these patients.     

Long-term renal function and survival of renal transplant recipients admitted to the intensive care unit

Arulkumaran N, West S, Chan K, Templeton M, Taube D, Brett SJ. Long‐term renal function and survival of renal transplant recipients admitted to the intensive care unit.
Clin Transplant 2012: 26: E24–E31.
© 2011 John Wiley & Sons A/S. Abstract: Introduction: We determined the long‐term mortality and renal allograft function of renal transplant recipients admitted to the intensive care unit (ICU). Methods: A single institution retrospective observational cohort study of all renal transplant patients admitted to the ICU was performed. Serum creatinine was recorded up to one yr after hospital discharge and survival data were collected for three yr. Results: Chest sepsis was the commonest reason for ICU admission. ICU and hospital mortality were 32% and 19% respectively. Predictors of hospital mortality included the presence of sepsis and duration of mechanical ventilation (MV). Of the patients who were discharged from ICU, three‐yr mortality was 50%. Renal function at one yr was worse than that at hospital discharge and at baseline, though not statistically significant. Death‐censored allograft loss was 11% over the three‐yr follow up period. Conclusions: Sepsis and requirement for MV are independent predictors of mortality in renal transplant recipients admitted to ICU. Renal transplant recipients with chest sepsis may warrant earlier ICU admission. Any loss of renal allograft function during an episode of critical illness appears to have a lasting effect, and longterm patient and allograft survival is poor.     

Outcomes from intensive care in patients with COVID-19: a systematic review and meta-analysis of observational studies

The emergence of coronavirus disease 2019 (COVID-19) has led to high demand for intensive care services worldwide. However, the mortality of patients admitted to the intensive care unit (ICU) with COVID-19 is unclear. Here, we perform a systematic review and meta-analysis, in line with PRISMA guidelines, to assess the reported ICU mortality for patients with confirmed COVID-19. We searched MEDLINE, EMBASE, PubMed and Cochrane databases up to 31 May 2020 for studies reporting ICU mortality for adult patients admitted with COVID-19. The primary outcome measure was death in intensive care as a proportion of completed ICU admissions, either through discharge from the ICU or death. The definition thus did not include patients still alive on ICU. Twenty-four observational studies including 10,150 patients were identified from centres across Asia, Europe and North America. In-ICU mortality in reported studies ranged from 0 to 84.6%. Seven studies reported outcome data for all patients. In the remaining studies, the proportion of patients discharged from ICU at the point of reporting varied from 24.5 to 97.2%. In patients with completed ICU admissions with COVID-19 infection, combined ICU mortality (95%CI) was 41.6% (34.0–49.7%), I² = 93.2%). Sub-group analysis by continent showed that mortality is broadly consistent across the globe. As the pandemic has progressed, the reported mortality rates have fallen from above 50% to close to 40%. The in-ICU mortality from COVID-19 is higher than usually seen in ICU admissions with other viral pneumonias. Importantly, the mortality from completed episodes of ICU differs considerably from the crude mortality rates in some early reports.     

The outcomes of critically ill patients with combined severe acute liver and kidney injury secondary to paracetamol toxicity requiring renal replacement therapy

There is a paucity of outcome data for critically ill patients with combined acute liver and kidney injury secondary to paracetamol overdose (POD) requiring renal replacement therapy (RRT). We retrospectively reviewed all admissions over a 6-year period to the intensive care unit (ICU) at a university teaching hospital which supports an active liver transplant program. Of the 5582 admissions over this period, 73 patients were admitted with combined liver and kidney injury requiring RRT, and of these 10 patients went on to receive a liver transplant. Overall mortality was 58%, being lower at 20% for transplant recipients. Transplant recipients were younger than non-transplanted patients with similar global disease severity scores [Model for End-Stage Liver Disease (MELD) and Acute Physiology and Chronic Health Evaluation II (APACHE II)]. Patients with a higher MELD or APACHE II score fared worse and patients fulfilling the King's College Hospital transplant criteria on admission had an odds ratio (OR) for death of 3.8 (1.3-10.6). Logistic regression modeling found that only a higher admission bilirubin OR 1.6 (1.1-2.3) mg/dL and a lower creatinine OR 0.52 (0.3-0.9) mg/dL were predictive of mortality. Of the ICU survivors, 41% remained RRT dependant at the time of ICU discharge; all regained independent renal function by 1 month. Combined severe acute liver and kidney injury secondary to POD requiring RRT is associated with a high mortality. The majority of survivors recover independent kidney function by 1 month. Standard disease severity scores appear to reflect prognosis in these patients.     

Comparison of the severity of illness scoring systems for critically ill cirrhotic patients with renal failure

BACKGROUND: Mortality rates of cirrhotic patients with renal failure admitted to the medical intensive care unit (ICU) are high. End-stage liver disease is frequently complicated by disturbances of renal function. This investigation is aimed to compare the predicting ability of acute physiology, age, chronic health evaluation II and III (APACHE II and III), sequential organ failure assessment (SOFA), and Child-Pugh scoring systems, obtained on the first day of ICU admission, for hospital mortality in critically ill cirrhotic patients with renal failure. METHODS: Sixty-seven patients with liver cirrhosis and renal failure were admitted to ICU from April 2001-March 2002. Information considered necessary for computing the Child-Pugh, SOFA, APACHE II and APACHE III score on the first day of ICU admission was prospectively collected. RESULTS: The overall hospital mortality rate was 86.6%. Liver disease was most commonly attributed to hepatitis B viral infection. The development of renal failure was associated with a history of gastrointestinal bleeding. Goodness-of-fit was good for SOFA, APACHE II and APACHE III scores. The APACHE III and SOFA models reported good areas under receiver operating characteristic curve (0.878 +/- 0.050 and 0.868 +/- 0.051, respectively). CONCLUSION: Renal failure is common in critically ill patients with cirrhosis. The prognosis for cirrhotic patients with renal failure is poor. APACHE III and SOFA showed excellent discrimination power in this group of patients. They are superior to APACHE II and Child-Pugh scores in this homogenous group of patients.     

Epidural anesthesia improves outcome and resource use in cardiac surgery: a single-center study of a 1293-patient cohort

Thoracic epidural anesthesia (TEA) combined with general anesthesia in cardiac surgery has the potential to initiate earlier spontaneous ventilation and extubation, improved hemodynamics, less arrhythmia or myocardial ischemia, and an attenuated neurohormonal response. The aim of the current study was to characterize the correlation between TEA and postoperative resource use or outcome in a consecutive-patient cohort. The study was performed in a tertiary care, 3-surgeon, university-affiliated hospital that performs 350 to 400 cardiac surgeries per year. All 1293 adult patients who underwent cardiac surgery between July 1, 2002, and February 1, 2006, were included. Patients were assigned to anesthesiologists practicing TEA (TEA group, n = 506) or not (control group, n = 787) for cardiac surgery. The preoperative parameter values and Parsonnet scores for the 2 groups were similar. The 2 groups had the same distribution of surgery types. The TEA group presented with fewer intensive care unit (ICU) complications, such as delirium, pneumonia, and acute renal failure, and presented with better myocardial protection. The TEA group presented with a higher proportion of immediately postoperative extubations and with shorter ventilation times and ICU stays. Total ICU costs decreased from US $18,700 to $9900 per patient. Combining TEA and general anesthesia for cardiac surgery allows a significant change in anesthesia strategy. This change improves immediate postoperative outcomes and reduces the use and costs of ICU resources.     

Efficacy of haemofiltration during cardiopulmonary bypass in paediatric open heart surgery

Purpose Haemofiltration is a useful method for removing fluid overload in paediatric patients undergoing open heart surgery. However, its role in reducing the inflammatory response to cardiopulmonary bypass (CPB) is still controversial. This study was undertaken to examine the efficacy of haemofilter in reducing the inflammatory response to CPB in paediatric patients undergoing open heart surgery. Methods We studied 20 paediatric patients undergoing open heart surgery with long duration CPB. In ten patients conventional methods of suppressing inflammation, like aprotinin and methylprednisolone were used and in the other ten patients, haemofiltration was added to the conventional methods. Inflammatory response was assessed by increase in total white blood cell counts and decrease in complement factor 3 (C3) levels. Patients were followed up in the intensive care unit. Result The fall in C3 concentration and increase in WBC counts was significantly more in conventional group (29.1% and 81% respectively) as compared to the haemofilter group (11.4% and 37% respectively). However, it did not reflect on any significant increase in postoperative PaO2, decrease in mechanical ventilation or ICU stay. Conclusion Use of haemofilter decreases the inflammatory response, but its clinical implication in postoperative period is still not clear.     

Emergency intensive care admission following elective thoracic surgery

AIM: The aim of this study was to analyse the outcomes of patients admitted to the intensive care unit (ICU) following initial recovery after elective thoracic surgery. METHODS: The case notes of all patients who underwent elective thoracic surgery over a one-year period were reviewed. Patients who were admitted to ICU following an initial recovery on the ward were identified and their postoperative course analysed. The clinical and demographic characteristics of these patients were recorded and their outcomes analysed. RESULTS: A total of 20 patients were admitted to ICU of whom 13 (65%) were admitted for respiratory complication, 5 with sepsis and 2 with cardiovascular instability. Sixteen (80%) patients required CPAP or BIPAP, of whom only 7 (35%) required mechanical ventilation. Renal support was required in 7 patients, with 2 (10%) requiring haemofiltration. ICU survival was 15 patients (75%), whilst overall three-month survival post ICU admission was 65%. Requirement for renal support was the only predictor of mortality on univariate and multivariate analysis. CONCLUSIONS: Salvage ICU admission following elective thoracic surgery is associated with significant mortality, however the outcome is far from hopeless. The majority of patients can be managed without recourse to mechanical ventilation or haemofiltration. The need for renal support is, however, a significant adverse prognostic indicator.     

The predictors and outcome of recidivism in cardiac ICUs.

OBJECTIVE: Reinstitution of step-up care (recidivism) following cardiac surgery may be associated with increased mortality. This has, however, not been widely reported. METHODS: We, therefore, studied 8113 consecutive patients who underwent coronary artery bypass grafting (CABG), valve replacement/repair or combined valve+CABG surgery between January 1996 and December 2003 to determine the reasons for readmission to the intensive care unit (ICU) and their outcomes in terms of length of stay in (i) the ICU (ii) hospital and (iii) the in-hospital mortality following recidivism. RESULTS: Of the 7717 patients discharged out of the ICU, 2.3% (182) of patients [mean age 70.4+/-8.35 years (range 30-90 years); 65.4% (119) males] required step-up care. Recidivism was 1.8% (101 of 5633) following coronary artery by-pass grafting (CABG) and 3.9% (81 of 2084) following valve replacement/repair+/-CABG (P<0.05). The mean interval from ICU discharge to ICU recidivism was 6.6+/-8.4 days (range 6h to 28 days). The principal reasons for recidivism were (i) respiratory failure requiring reintubation and ventilation in 54.9% (n=100) of patients (ii) cardiovascular instability (including that secondary to dysrhythmias) and heart failure in 23.1% (n=42) (iii) renal failure requiring haemofiltration in 6.6% (n=12) (iv) sepsis in 1.1% (n=2) (v) cardiac tamponade/bleeding requiring re-exploration in 7.7% (n=14) and (vi) gastro-intestinal complications requiring laparotomy in 6.0% (n=11) patients. Multivariate analysis showed that, during primary ICU stay, respiratory complications, low cardiac output state, dysrhythmias, renal failure requiring haemofiltration and re-exploration for bleeding were independent predictors of recidivism. Following recidivism (i) the mean length of stay in the ICU was 6.65+/-6.2 days (range 4h to 51 days), (ii) mean hospital stay was 19.2+/-17.3 days (10-60 days) and (iii) the 30-day in-hospital mortality was 32.4%. CONCLUSIONS: Patients are more likely to require recidivism following valve surgery+/-CABG than CABG alone. Whilst respiratory complications were the most common reasons for recidivism in our study, patients who required mechanical supports to maintain vital functions following surgery were most prone to recidivism. Hence, efforts should be made to treat cardio-respiratory problems early in this group of patients to reduce ICU recidivism.