Review of the Utility of Extended Recovery Room Observation after Adenotonsillectomy

Background: Our institution implemented a post-anesthesia care unit (PACU) extended-stay model (Grey Zone model), where the post-operative level of care for high-risk adenotonsillectomy patients (general care vs. intensive care unit) was decided based on the clinical course of 2–4 h of PACU admission. Objective: To assess the correlation between post-tonsillectomy respiratory compromise and the need for respiratory support during an extended stay at PACU. To identify comorbidities associated with a need for intensive care after extended observation. Methods: A retrospective cohort study of high-risk children who underwent adenotonsillectomy and were admitted to the Grey Zone following surgery. Results: 274 patients met inclusion criteria. 262 (95.6%) met criteria for general care unit transfer (mean oxygen saturation 94.4 ± 5.1%). Twelve (4.4%) patients were transferred from the PACU to the ICU due to respiratory distress (mean oxygen saturation 86.8 ± 11%). Of the patients admitted to general care, 4 (1.5%) secondarily developed respiratory compromise, requiring escalation of care. Three of these maintained oxygen saturation ≥95% throughout the PACU period. There was no difference between the groups with respect to demographic data, rates of morbid obesity, and severity of obstructive sleep apnea. Neuromuscular disease, chronic lung disease, seizure disorder, and gastrostomy-tube status were more prevalent in those requiring ICU level of care compared to the general care unit. Conclusions: The Grey Zone model accurately identifies patients requiring ICU-level care following adenotonsillectomy, allowing for a safe reduction in the utilization of ICU resources. Due to rare delayed respiratory events, overnight observation in this cohort is recommended. Level of Evidence: 4 Laryngoscope, 133:3582–3587, 2023.