Background: Elective pediatric upper airway procedures are generally safe; however, some patients require unplanned pediatric intensive care unit admission, increasing care complexity.
Aims: To identify perioperative risk factors associated with unplanned pediatric intensive care unit admission following elective pediatric upper airway surgery.
Methods: We performed a retrospective case-control study at a single tertiary care center, identifying all unplanned pediatric intensive care unit admissions between January 2017 and June 2022. Among 151 such admissions, 29 followed elective upper airway surgery; of these, 22 cases were successfully matched on procedure type, age, and date of surgery in a 1:2 ratio to controls without unplanned pediatric intensive care unit admission based on procedure type, age, and date of surgery. Demographic, clinical, and perioperative variables were compared between cases and controls.
Results: The unplanned pediatric intensive care unit admission (n = 22) and control (n = 44) groups were comparable with respect to age and weight; however, median apnea-hypopnea index was higher in the unplanned pediatric intensive care unit cohort (12.7 [IQR 7.9-33.7] vs. 6.6 [IQR 3.7-25.2] events/h; p = 0.033). In unadjusted conditional logistic regression analyses, American Society of Anesthesiologists physical status > 2 was associated with increased odds of unplanned pediatric intensive care unit admission (OR 7.92, 95% CI 2.25-27.92; p = 0.001), as were prior neonatal intensive care unit admission (OR 23.19, 95% CI 3.03-177.38; p = 0.003), chronic lung disease (OR 14.00, 95% CI 1.72-113.79; p = 0.014), and longer operative duration (OR 1.03 per minute, 95% CI 1.003-1.058; p = 0.032). Apnea-hypopnea index, analyzed using multiple imputed values, was not significant (OR 1.03 per unit increase, 95% CI 0.996-1.069; p = 0.082). In a multivariable conditional logistic regression model, only prior neonatal intensive care unit admission remained independently associated with unplanned pediatric intensive care unit admission (adjusted OR 14.65, 95% CI 1.23-175.05; p = 0.034).
Conclusion: Several clinical factors were seen to be associated with increased risk of unplanned pediatric intensive care unit admission after upper airway surgery including American Society of Anesthesiologists physical status > 2, chronic lung disease, prior neonatal intensive care unit admission, and longer operative duration. Controlling for these clinical factors, prior neonatal intensive care unit admission best predicted the need for unplanned pediatric intensive care unit admission. Recognition of these risk factors may help inform perioperative risk stratification and postoperative resource planning.
Keywords: intensive care units; obstructive sleep apnea; pediatric; pediatric anesthesia; postoperative complications; risk assessment.
© 2026 The Author(s). Pediatric Anesthesia published by John Wiley & Sons Ltd.