ORIGINAL ARTICLE Pre-operative parameters do not reliably identify post-operative respiratory risk in children undergoing adenotonsillectomy Surendran Thavagnanam , 1,2 Saou Y Cheong, 3 Karuthan Chinna, 4 Anna M Nathan 1,2 and Jessie A de Bruyne 1,2 1 Department of Paediatrics, 2 University Malaya Paediatric and Child Health Research Group, 3 Faculty of Medicine and 4 Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia Aim: Adenotonsillectomy is performed in children with recurrent tonsillitis or obstructive sleep apnoea. Children at risk of post-operative respira- tory complications are recommended to be monitored in paediatric intensive care unit (PICU). The aim of the study is to review the risk factors for post-operative complications and admissions to PICU. Methods: A review of medical records of children who underwent adenotonsillectomy between January 2011 and December 2014 was per- formed. Association between demographic variables and post-operative complications were examined using chi-square and Mann–Whitney tests. Results: A total of 214 children were identified, and of these, 19 (8.8%) experienced post-operative complications. Six children (2.8%) had respira- tory complications: hypoxaemia in four and laryngospasm requiring reintubation in a further two. Both of the latter patients were extubated upon arrival to PICU and required no escalation of therapy. A total of 13 (6.1%) children had non-respiratory complications: 8 (3.7%) had infection and 5 (2.3%) had haemorrhage. A total of 26 (12.1%) children were electively admitted to PICU and mean stay was 19.5 (SD Æ 13) h. No association between demographic characteristics, comorbid conditions or polysomnographic parameters and post-operative complications were noted. A total of 194 (90.7%) children stayed only one night in hospital (median 1 day, range 1–5 days). Conclusion: The previously identified risk factors and criteria for PICU admission need revision, and new recommendations are necessary. Key words: adenotonsillectomy; complication; obstructive sleep apnoea; post-operative. What is already known on this topic 1 In children undergoing adenotonsillectomy, the rate of respira- tory complications ranges from 11% to 20%. 2 The most important predictors of post-surgical respiratory mor- bidity were young age, obesity and the initial severity of obstruc- tive sleep apnoea syndrome (OSAS). 3 As such, it is recommended that these children would need to be observed post-operatively in paediatric intensive care unit (PICU). What this paper adds 1 No association between demographic characteristics, comorbid conditions or polysomnographic parameters and post-operative complications were noted. 2 The previously identified risk factors and criteria for PICU admis- sion need revision and new recommendations are necessary. Adenoidectomy and/or adenotonsillectomy (AT) remain the most common surgical option for children with recurrent tonsillitis 1 and adenotonsillar hypertrophy causing obstructive sleep apnoea (OSA). 2,3 Previous studies have identified potential post-operative respiratory complications 4–8 in children following AT and a num- ber of risk factors have been identified such as age below 3 years, obesity, severe OSA (apnoea hypopnoea index (AHI) > 10 events/ h), genetic syndromes, craniofacial abnormalities and neuromus- cular diseases. 4,9–12 These risk factors were identified from a heterogeneous populations 2 and may not be supported by poly- somnography (PSG). Also varied definitions of post-operative com- plications were used, which may have overestimated the true number of complications. All of these broad classifications may not necessary be applicable these days since there have been improve- ment in medical and surgical techniques for AT. In view of the possible post-operative complications, centres have adopted a blanket policy to electively admit the at-risked children to paediatric intensive care unit (PICU) following AT for close monitoring. Obtaining a bed in PICU is often difficult; there- fore, when a policy of routine admissions are in place, some of the AT cases are often cancelled when no PICU bed is available. This lengthens the wait time for surgery and may indirectly worsen the child’s comorbidities. Recently, Theilhaber et al. recommended routine post-operative ICU admission is not rou- tinely needed but only in the presence of early adverse events (AEs) in recovery period. 13 Correspondence: Associate Professor Surendran Thavagnanam, Depart- ment of Paediatrics, University Malaya Medical Centre, Lembah Pantai, Kuala Lumpur 50603, Malaysia. Fax: +60 37949 4704; email: surendran@ummc.edu.my Conflict of interest: None declared. Accepted for publication 16 September 2017. doi:10.1111/jpc.13789 530 Journal of Paediatrics and Child Health 54 (2018) 530–534 © 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)