Predicting respiratory complications in paediatric adenotonsillectomy: A risk stratification protocol

Background: This study aims to determine whether a peri-operative guideline developed at an Australian multicentre health network was able to successfully stratify children undergoing adenotonsillectomy (AT) with varying risk of post-operative respiratory compromise to an appropriately supported site. Methods: A retrospective cohort study reviewing 1,923 children between 2- and 12-year-old undergoing AT for obstructive sleep apnoea (OSA) between January 2011 and December 2017. Protocol adherence, frequency of adverse events (AE) and site at which AE occurred were compared. Univariable and multivariable logistic regression modelling was used to identify independent factors associated with this outcome. Results: In total, 1,923 patients were identified and triaged according to protocol; 1,019 patients underwent surgery at a higher acuity centre, with 137 respiratory AE (13.4%), and 904 were managed at a lower acuity centre, with 11 AE (1.2%). Patients at the higher acuity centre had 11.68-fold increased odds of post-operative AE (95% CI, 6.25–21.81; P<0.0001). Risk factors associated with post-operative AE included: severe OSA on either pre-operative home oximetry or polysomnography (PSG) [odds ratio (OR), 6.38; 95% CI, 3.72–10.94; P<0.0001], age ≤2 (OR, 2.65; 95% CI, 1.69–4.15; P<0.0001), and the presence of a recovery room complication (OR, 9.28; 95% CI, 2.41–35.77; P=0.001). Protocol adherence between care settings was 97%. Conclusions: Pre-operative oximetry and/or PSG, as part of a peri-operative risk stratification protocol in children undergoing AT for OSA, can successfully predict the risk of respiratory AE. This allows for an appropriate care setting to be determined pre-operatively, limiting the occurrence of AE in under-resourced care settings, inter-hospital transfers and unplanned ICU admissions.