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Patients undergoing adenotonsillectomy (T&A) for severe obstructive sleep apnea (OSA) are usually admitted for observation, and many surgeons use the intensive care unit (ICU) for observation due to the risk of postsurgical airway obstruction. Given the limited resources of the pediatric ICU (PICU), there is a push to better define the patients who require postoperative monitoring in the PICU for monitoring severe OSA.Forty-five patients were evaluated. Patients who had cardiac or craniofacial comorbidities were excluded. Patients undergoing T&A for severe OSA were monitored in the postanesthesia care unit (PACU) postoperatively. If patients required supplemental oxygen or developed hypoxia while in the PACU within the 3-hour monitoring period, they were admitted to the PICU.Overall, 16 of 45 patients were admitted to the ICU for monitoring. Patients with an Apnea-Hypopnea Index (AHI) >50 or with an oxygen nadir <80% were significantly more likely to be admitted to the PICU. The mean AHI of patients admitted to the PICU was 40.5, and the mean oxygen nadir was 69.9%. Patients younger than 2 years were significantly more likely to be admitted to the PICU.Based on the data presented here and academy recommendations, not all patients with severe OSA require ICU monitoring.