We describe the incidence of and define risk factors for pressure ulcers (PU) in the surgical intensive care unit (ICU). Twelve months of data were collected on all patients admitted to the intensivist-run surgical ICU of a university hospital. PU patients were those who developed a new stage II or greater lesion during or after a surgical ICU stay as identified in Project Impact, ICD9 discharge, or ICU complications databases. Patients were nursed in pressure-relieving beds with nutrition initiated by 72 hours. Chi2, t test, and logistic regression statistics were used. Three percent (25/820) developed PU. Age, ICU length of stay, Acute Physiology and Chronic Health Evaluation Score (APACHE), and gender were not different between those with and without PU. Patients with PU had a higher blood urea nitrogen/creatinine (30.5/2.2 mg/dL vs 22.0/1.6 mg/dL) and were more frequently vascular patients (28 vs 14.1%), diabetics (40 vs 17.2%), paraplegics (8 vs 0.2%) (all P < 0.01), and patients on pressors (28.0 vs 11.8%, P < 0.02). Multivariate analysis revealed that diabetes (odds ratio [OR] 2.7, 95%, confidence interval [CI] 1.1-6.4), spinal cord injury (OR 16.8, 95%, CI 1.5-183), age > 60 years (OR 2.9, 95%, CI 1.2-7.1), and a creatinine >3 mg/dL (OR 3.7, 95%, CI 1.2-9.3) were independent predictors of PU. Despite universal use of specialty beds and early nutrition, pressure ulcers developed in 3 per cent. Independent risk factors include age greater than 60 years, diabetes, spinal cord injury, and renal insufficiency. Additional modalities, such as aggressive early mobilization, might be warranted in this cohort.