Risk factors of peri-intubation cardiac arrest
in critically ill pediatric patients presenting

to the emergency department of a low-
middle-income country: a case-control study

Risk factors of peri-intubation cardiac arrest
in critically ill pediatric patients presenting

to the emergency department of a low-
middle-income country: a case-control study

Peri-intubation, Cardiac arrest, Pediatric, Emergency department, Case-control

Abstract
Background Peri-intubation cardiac arrest is defined as cardiac arrest that occurs within 20 min of airway
management. Incidence in the pediatric population ranges from 0.7% to 1.7%. Identifying pre-intubation risk factors
may improve preparedness and outcomes during emergency intubations. This study aims to identify clinical and
physiological predictors associated with peri-intubation cardiac arrest in pediatric patients undergoing emergency
airway management in a tertiary care emergency department.
Methods A retrospective case-control study was conducted at the emergency department of a tertiary care hospital
in Karachi, Pakistan, from January 2019 to June 2023. Pediatric patients (<18 years) who experienced cardiac arrest
within 20 min of intubation were included as cases. For each case, four controls were randomly selected from the
same cohort who were intubated without arrest. Pre-intubation clinical data, laboratory parameters, and vital signs
were analyzed. Multivariable logistic regression was used to identify independent predictors of peri-intubation cardiac
arrest.
Results A total of 1031 pediatric patients underwent intubation in the ED, with 25 cases (2.4%) of peri-intubation
cardiac arrest identified. For comparison, 100 controls without cardiac arrest were randomly selected, resulting in a
total study cohort of 125 patients. Multivariate analysis identified several independent predictors of peri-intubation
cardiac arrest. Age less than one year (aOR: 4.37; p=0.042), hypoxemia (SpO2 < 92%) (aOR: 19.81; p=0.003), elevated
heart rate (aOR: 1.42; p=0.045), low systolic blood pressure (aOR: 6.56; p=0.043), elevated shock index (≥1.2) (aOR:
5.52; p=0.046), modified shock index≥1.3 (aOR: 6.27; p=0.012), lactate≥2 mmol/L (aOR: 10.09; p=0.047) and capillary
refill time>3 s (aOR: 5.78; p=0.038), were found to be independent predictors of peri-intubation cardiac arrest.
Conclusion Pre-intubation physiological instability is strongly associated with peri-intubation cardiac arrest in
pediatric patients. Early recognition of high-risk features such as hypoxemia, tachycardia, hypotension, elevated
lactate levels, delayed capillary refill time, and elevated shock indices may allow for better preparation and

Noman Ali1*, Erum Shakeel1

, Ahmed Raheem1

, Hania Ather1

and Surraiya Bano1

https://doi.org/10.1186/s12245-025-01099-5

2025

Peri Irawan

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