Identifying High-Risk Children Safe for Same-Day Discharge After Tonsillectomy

Objective: Current guidelines recommend overnight admission for children with severe obstructive sleep apnea (OSA) and obesity undergoing tonsillectomy, although most have uneventful postoperative courses. We aimed to identify low-risk subgroups within this high-risk population who may be candidates for same-day discharge. Methods: Retrospective cohort study of children aged 2–18 years with obesity (≥ 95th BMI percentile) and severe OSA (AHI ≥ 10 events/h and/or SpO₂ nadir < 80%) undergoing tonsillectomy at a tertiary children's hospital (2021–2024). The primary outcome was a severe perioperative event: ICU admission, prolonged hospitalization (> 48 h), or need for advanced respiratory support. Bayesian logistic regression using informative priors identified predictors. Model-based risk stratification and simplified clinical rules were evaluated using sensitivity, specificity, and negative predictive value. Results: Among 304 children, 36 (11.8%) experienced a severe event. SpO₂ nadir was the strongest predictor (β = −0.668, 95% CrI [−1.164, −0.172], directional probability 99.6%), followed by Class III obesity (97.0%) and AHI (95.0%). Model-derived stratification identified 33% of patients with < 5% predicted probability of severe events. A clinical rule combining AHI < 25 events/h and SpO₂ nadir > 85% showed sensitivity 85.7% and negative predictive value 99.5%, corresponding to an observed event rate < 5%. Conclusion: Most obese children with severe OSA do not experience severe perioperative events. Simple polysomnographic criteria can identify very low-risk patients who may be candidates for same-day discharge planning. These findings support a more individualized approach to postoperative admission; prospective validation is needed before implementation. Level of Evidence: 4.