OBJECTIVE: Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation.

METHODS: A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure < 65 mmHg; 2) systolic blood pressure < 80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation.

RESULTS: Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure < 65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients’ pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients’ risk of hypotension.

CONCLUSIONS: A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients.

STUDY REGISTRATION: Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.

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Published in PLOS ONE, v. 15, no. 8, e0233852.

© 2020 Smischney et al.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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All relevant data are within the paper and its Supporting Information files (specifically S8 Table).

All Supporting Information files are available for download as the additional files listed at the end of this record.

pone.0233852.s001.DOCX (15 kB)
S1 Table. HEMAIR collaborators. HEMAIR: HEModynamic and AIRway collaborators, HHS: Health & Human Services. https://doi.org/10.1371/journal.pone.0233852.s001

pone.0233852.s002.DOCX (15 kB)
S2 Table. Candidate predictor variables. https://doi.org/10.1371/journal.pone.0233852.s002

pone.0233852.s003.DOCX (18 kB)
S3 Table. Data analysis centers. HHS: Health & Human Services. https://doi.org/10.1371/journal.pone.0233852.s003

pone.0233852.s004.DOCX (15 kB)
S4 Table. Summary of cases experiencing each individual outcome (0 = no, 1 = yes). SBP: systolic blood pressure, MAP: mean arterial pressure. https://doi.org/10.1371/journal.pone.0233852.s004

pone.0233852.s005.DOCX (60 kB)
S5 Table. Calibration plots (Patients grouped according to deciles of predicted risk score. https://doi.org/10.1371/journal.pone.0233852.s005

pone.0233852.s006.DOCX (53 kB)
S6 Table. Receiver Operating Characteristic (ROC) curves. https://doi.org/10.1371/journal.pone.0233852.s006

pone.0233852.s007.DOCX (44 kB)
S7 Table. Predicted risk of post-intubation hypotension by risk score. https://doi.org/10.1371/journal.pone.0233852.s007

pone.0233852.s008.csv (172 kB)
S8 Table. Minimal underlying data set. https://doi.org/10.1371/journal.pone.0233852.s008

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