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Low Parental Decisional Regret in Patients Receiving Spinal and General Anesthesia for Pediatric Urologic Surgery
Kristin Ebert, MD, Lindsey Asti, MPH, Tran Bourgeois, MPH, Jermain Byers, BS, Seth Alpert, MD, Christina Ching, MD, Daniel Dajusta, MD, Molly Fuchs, MD, Rama Jayanthi, MD, Daryl McLeod, MD.
Nationwide Children's Hospital, Columbus, OH, USA.

Background: Studies on spinal anesthesia (SA) for pediatric urologic surgery have demonstrated that this technique obviates the need for advanced airways, decreases need for intra-operative narcotics, and has a low complication rate. At our institution, we promote these benefits to parents, but we have not previously examined parental satisfaction or anxiety regarding the choice for SA and general anesthesia (GA). We aimed to describe decisional regret and anxiety levels in parents of children receiving SA and GA for pediatric urologic surgery.
Methods: This was a single-institution prospective observational cohort study. Parents of patients aged 4-12 months undergoing any of six standard elective pediatric urologic surgeries (circumcision/revision, scrotoplasty, chordee release, orchiopexy, or inguinal hernia repair) were approached between October 2020 and May 2021 for study enrollment. We excluded non-English speakers and patients with a contraindication to SA/GA. The surgical team offered parents both anesthesia types, who then decided on a type after a discussion with the anesthesiologist. Patients were classified based on intention-to-treat (i.e. if a SA patient was converted to GA; they were classified as SA in the analysis).While their child was in surgery, parents completed a demographic survey, the validated State Trait Anxiety Inventory (STAI), and the Chew validated health literacy screening questionnaire. One week later, parents were contacted by phone to complete the Decisional Regret Scale (DRS), a validated measure that corresponds with satisfaction of medical decision-making. We collected clinical information, including
patient age, surgery type, and surgical/anesthetic complications, via electronic chart review. Our primary outcome was measured by DRS score, dichotomized into no/mild regret (0-25) and moderate/severe regret (>25). Our secondary outcome was measured by score on the STAI, also in a categorical fashion (0-40: no/subclinical anxiety, >40 clinical anxiety). Due to small sample size, statistics are descriptive only. Results: 58 patients were recruited for the study (45 SA, 13 GA). Median patient age was 8.6 months in SA group and 7.2 months in GA group. Nearly all surveys were completed by the mother (52/58). Overall, only 4 (6.9%) parents expressed regret with their decision (6.7% in SA group and 7.7% in GA group). Frequency of clinical anxiety was 37.8% in the SA group and 15.4% in the GA group. Frequency of low health literacy was 13% in SA
group and 54% in GA group. Additional demographic/clinical characteristics are listed in Table 1.Conclusions: Parents rarely indicate decisional regret for the type of anesthesia they chose for their child during pediatric urology surgery. However, parents who choose SA may have more anxiety than parents who choose GA, and parents with low health literacy may be less likely to choose SA. Better patient education may be needed to increase utilization of SA in this population.
Table 1. Demographics and outcomes between parents/ guardians who chose spinal or general anesthesia (based on intended group assignment)

Spinal (n=45)General (n=13)
n (%)n (%)
Parent or guardian characteristics
Age, in years [median (IQR)] (n=57)31.0 (27.0 - 34.0)32.0 (28.0 - 35.0)
Other7 (15.6)3 (23.1)
Non-Hispanic White38 (84.4)10 (76.9)
Marital status
Never married/divorced9 (20)2 (15.4)
Married/domestic partners36 (80)11 (84.6)
Highest level of education
Some high school, high school graduate/GED19 (42.2)8 (61.5)
Bachelor''s degree15 (33.3)3 (23.1)
Master's degree or higher11 (24.4)2 (15.4)
Surgery details
Type of surgery
Circumcision21 (46.7)7 (53.8)
Circumcision revision8 (17.8)1 (7.7)
Scrotoplasty/repair of penoscrotal webbing9 (20.0)4 (30.8)
Chordee release6 (13.3)1 (7.7)
Orchiopexy8 (17.8)4 (30.8)
Inguinal hernia/hydrocele repair7 (15.6)5 (38.5)
Hidden/buried penis repair23 (51.1)5 (38.5)
Number of procedures
116 (35.6)3 (23.1)
221 (46.7)6 (46.2)
38 (17.8)4 (30.8)
Time away from parent/guardian, in minutes [median (IQR)] (n=57)112.0 (100.0 - 153.0)64.0 (54.0 - 78.5)
Anesthesia complication1 (2.2)2 (15.4)
Surgical complication0 (0)0 (0)
Low health literacy6 (13.3)7 (53.8)
Anxiety (STAI>40)17 (37.8)2 (15.4)
Decisional regret scale (DRS>25)3 (6.7)1 (7.7)

GED=General Educational Development; IQR=interquartile range; STAI=State Trait Anxiety Inventory.

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