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Published on: November 6, 2019

Mediating effects of postoperative complications in children with high-risk obstructive apnea following

Antara Gupta1, Hanna Gedamu1, Yann-Fuu Kou2

  • 1University of Texas Southwestern Medical School, Dallas, TX, USA.

International Journal of Pediatric Otorhinolaryngology
|June 4, 2026
PubMed

Insights

Pediatric obstructive sleep apnea (OSA) severity impacts postoperative complications through oxygen levels and CO2. Time spent below 90% oxygen (TST O2 <90%) is a key mediator, aiding risk identification in children undergoing adenotonsillectomy.

Area of Science:

  • Pediatric Sleep Medicine
  • Anesthesiology
  • Otolaryngology

Background:

  • Pediatric patients with high-risk obstructive sleep apnea (OSA) face increased postoperative complications after adenotonsillectomy (AT).
  • Previous studies identified risk factors but did not explore mediating variables explaining the link between OSA severity and complications.
  • Identifying these mediators is crucial for better risk stratification and targeted interventions in this population.

Purpose of the Study:

  • To investigate the mediating variables that explain how high-risk obstructive sleep apnea (OSA) severity contributes to postoperative complications in pediatric patients undergoing adenotonsillectomy (AT).
  • To identify specific polysomnography (PSG) parameters that mediate the relationship between OSA and adverse outcomes.

Main Methods:

  • Causal-mediation analysis was performed on 307 pediatric patients (<18 years) with high-risk OSA who underwent AT and PSG between 2019 and 2021.
  • Primary outcomes included intensive care unit (ICU) intervention, major respiratory intervention, and prolonged hospitalization (>48 hours).
  • Twenty-five patient characteristics and PSG parameters were analyzed as potential mediators.

Main Results:

  • The relationship between high-risk OSA and postoperative complications was significantly mediated by O2 nadir, CO2 max, and time spent with oxygen saturation below 90% (TST O2 <90%).
  • Sensitivity analyses indicated that these mediation effects are sensitive to moderate levels of unmeasured confounding.

Conclusions:

  • Time spent with oxygen saturation below 90% (TST O2 <90%) emerged as a novel and consistent mediator, potentially identifying high-risk patients missed by simple OSA severity scores.
  • While causal mediation analysis identified key variables, sensitivity analyses highlight the need for cautious interpretation due to potential unmeasured confounding.
Abstract

Keywords:
High-risk sleep apneaObstructive sleep apneaPostoperative complicationscausal mediation analysis

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