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SpinalAnesthesia in Urology for Responsive Pediatric Anesthesia and Satisfaction in Surgery (SuRPaSS): A novel pediatric awake spinal anesthetic program
Marjorie M. Johnson, MD1, Matthew Cao, MD1, Alexander Radaoui, MD1, Erin Mayeux, MD1, David Heap, Jr., MD2, Rafael Morales Grimany, MD1, Emmett Whitaker, MD1, Heather N. Di Carlo, MD1, Ming-Hsien Wang, MD1, Sapna Kudchadkar, MD1, Chad B. Crigger, MD3, Tricia Vecchione, MD1.
1Johns Hopkins, Baltimore, MD, USA, 2University of Louisville, Louisville, KY, USA, 3Medical University of South Carolina, Charleston, SC, USA.
BACKGROUND: General anesthesia (GA) carries an elevated risk in children below age one, including increased rates of perioperative cardiac arrest, respiratory complications, and potential long-term neurocognitive effects with repeated exposure. Spinal anesthesia (SA) offers a viable alternative for short infraumbilical procedures. Multiple studies have demonstrated its safety in the pediatric urologic setting. However, caregiver satisfaction with SA has never been formally evaluated. We sought to implement a novel infant SA program at our institution and to evaluate caregiver satisfaction with SA compared with GA and those who underwent conversion from SA to GA (GA-C).
METHODS: We developed and implemented a single-institution, multiphase SA program at a large tertiary referral pediatric center. During the first phase, anesthesia staff participated in workshops focused on the SA technique. Additionally, perioperative nursing staff underwent education regarding SA candidacy and postoperative expectations. Clinical implementation occurred from September 2024 to November 2025. Males aged 24 months or younger undergoing noncomplex outpatient urologic procedures were eligible. Prospective clinical data, pain medication usage, and caregiver satisfaction surveys were collected for all patients. The primary outcome was caregiver satisfaction with the type of anesthetic. Secondary outcomes included SA success rate, conversion rate to GA, anesthesia time, procedure time, total OR time, PACU length of stay, and intraoperative and postoperative complications.
RESULTS: Two hundred and two male patients met the inclusion criteria (mean age 7.80 months [SD 4.58], mean weight 8.49 kg [SD 2.07]). SA was attempted in 163 patients; 143 (87.7%) were successful, and 20 (12.3%) required conversion to GA. Thirty-nine patients underwent planned GA. The most common procedure was circumcision (31%). Among patients with successful SA, the median age was 6.0 months (IQR 4.5-8.5). SA was associated with both significantly shorter anesthesia time and significantly shorter total OR time for circumcision, circumcision revision, circumcision with additional cosmetic penile procedures, and hypospadias repair (all p<0.05). Hypospadias repair was the only procedure with a significant difference in procedure time (SA 72.0 min vs. GA 126.0 min, p=0.001). SA was associated with a shorter PACU length of stay compared with GA (median 71.0 min [IQR 51.5-76.0] vs. 128.0 min [IQR 120.0-135.0]; p=0.013) among those undergoing circumcision. Intra-operative complication rates were low (1.9%), and all were transient. Caregiver satisfaction was high and statistically comparable across all cohorts (median composite score: SA 4.60/5 [IQR 4.25-4.90], GA 4.50/5 [IQR 4.13-4.75], GA-C 4.35/5 [IQR 3.53-4.72]; p=0.077).
CONCLUSIONS:Our experience demonstrates that an SA program can be safely implemented with high technical success and low complication rates at a high-volume children's hospital. SA was associated with reduced anesthesia and OR time for many common procedures. Caregiver satisfaction is high and comparable to GA. These findings support the broader adoption of structured SA programs in pediatric urology.
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