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Our primary aim was to identify predictors of immediate hemodynamic decompensation during the peri-intubation period.We conducted a nested case-control study of a previously identified cohort of adult patients needing intubation admitted to a medical-surgical ICU during 2013–2014. Hemodynamic derangement was defined as cardiac arrest and/or the development of systolic blood pressure <90 mm Hg and/or mean arterial pressure <65 mm Hg 30 min following intubation. Data during the peri-intubation period was analyzed.The final cohort included 420 patients. Immediate hemodynamic derangement occurred in 170 (40%) patients. On multivariate modeling, age/10 year increase (OR 1.20, 95% CI 1.03–1.39, p = 0.02), pre-intubation non-invasive ventilation (OR 1.71, 95% CI 1.04–2.80, p = 0.03), pre-intubation shock index/1 unit (OR 5.37 95% CI 2.31–12.46, p ≤ 0.01), and pre-intubation modified shock index/1 unit (OR 2.73 95% CI 1.48–5.06, p ≤ 0.01) were significantly associated with hemodynamic derangement. Those experiencing hemodynamic derangement had higher ICU [47 (28%) vs. 33 (13%); p ≤ 0.001] and hospital [69 (41%) vs. 51 (20%); p ≤ 0.001] mortality.Hemodynamic derangement occurred at a rate of 40% and was associated with increased mortality. Increasing age, use of non-invasive ventilation before intubation, and increased pre-intubation shock and modified shock index values were significantly associated with hemodynamic derangement post-intubation.