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

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 resuscitation planning. These findings support the need for structured pre-intubation assessment protocols in emergency settings.