Abstract

Background

Peri-intubation cardiac arrest is defined as cardiac arrest that occurs within 20 minutes of airway management [1]. Incidence in the pediatric population ranges from 0.7% to 1.7% [2, 3]. 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 (<18years) who experienced cardiac arrest within 20 minutes 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 125 pediatric patients were included, 25 cases and 100 controls. Multivariate analysis identified several independent predictors of peri-intubation cardiac arrest. Age less than one year (aOR:10.97; p=0.028), hypoxemia (SpO₂<92%) (aOR:5.48; p=0.047), elevated heart rate (aOR:2.88; p=0.029), low systolic blood pressure (aOR:6.16; p=0.043), elevated shock index (≥1.2) (aOR:5.52; p=0.046), modified shock index ≥1.3 (aOR:11.11; p=0.048), lactate ≥2 mmol/L (aOR:15.64; p=0.023), and capillary refill time >3 seconds (aOR:7.55; p=0.042), were found to be independent predictors of peri-intubation cardiac arrest (Table 1).

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.

Declarations
Conflicts Of Interests
The Authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Registration
No registration applicable.
Data availability statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.

Ethical approval
The research has been approved by the Ethical Review Committee of the Aga Khan University Hospital, Karachi, Pakistan
(2023-8659-24735).

References

1.      Esangbedo ID, Byrnes J, Brandewie K, Ebraheem M, Yu P, Zhang S, et al. Risk factors for peri-intubation cardiac arrest in pediatric cardiac intensive care patients: a multicenter study. Pediatr Crit Care Med. 2020 Dec 4;21(12):e1126–33. https://doi.org/10.1097/pcc.0000000000002472

2.      Pek JH, Ong GY. Emergency intubations in a high-volume pediatric emergency department. Pediatr Emerg Care. 2018 Dec 1;34(12):852–6. https://doi.org/10.1097/pec.0000000000001355

3.      Long E, Sabato S, Babl FE. Endotracheal intubation in the pediatric emergency department. Paediatr Anaesth. 2014 Dec;24(12):1204–11. https://doi.org/10.1111/pan.12490