Background & Aims

Virtual reality (VR) is a tool for managing anxiety and pain during medical procedures, such as needle insertion, dressing changes, and dental care (1). Up to 60% of children experience high levels of anxiety at induction of anesthesia (2, 3). This distress is post-operatively associated with a greater risk of emergence delirium, disturbed sleep, and behavioral and emotional disturbances, including anxiety, apathy, and withdrawal (4-6). A systematic review and meta-analysis found VR to be effective in reducing the anxiety of children undergoing elective surgery under general anesthesia (7). However, in most studies, VR was only used for singular, isolated timepoints, usually in the preoperative waiting room where children were provided a virtual tour of the operating room (OR). A better understanding of VR distraction throughout the entire peri-operative time frame, from the waiting room to induction of anesthesia, was needed to appreciate how it may be integrated in this setting.

Methods

A mixed-methods, concurrent triangulation, VR2 feasibility trial (8) was piloted at the Shriners Hospitals for Children®-Canada. Participants played a VR game (DREAM by Paperplane Therapeutics) in the pre-operative holding area, with the option of continuing on the way to the OR and during induction. Feasibility was examined with the intervention duration. Clinical utility was assessed using a perception questionnaire. Tolerability was evaluated by the child simulator sickness questionnaire (CSSQ). Initial clinical efficacy was assessed by the FACES Pain Scale-Revised, FACES Anxiety Scale, Graphic Rating Scale for multidimensional pain, the Induction Compliance Checklist (ICC), and the Pediatric Anesthesia Emergence Delirium (PAED) scale. Quantitative data was supported with qualitative data, including semi-structured interviews with patients and parents, and fieldnotes. Through the triangulation protocol (9), quantitative and qualitative findings were compared to produce final themes.

Results

Thirty-nine patients aged 6-18 years old (mean=11.9; SD=2.8) undergoing elective surgery under general anesthesia participated. Stakeholders were receptive and willing to adapt to VR. All patients used VR in the waiting room, 19 patients (48.7%) continued to use VR on the way to the OR, and six (15.4%) were induced with VR. Barriers to the feasibility of VR included: Interruptions to VR in 92.3% of patients, due to pre-operative assessments; occasionally long duration of VR use in the waiting room due to unpredictable surgery delays (mean=23.1 min; SD=24.4 min; range 5-150 min); and technical challenges during induction. The VR intervention was clinically useful and no self-reported simulator sickness was reported (CSSQ: mean=0.01). VR showed initial clinical efficacy, with a decrease of mean FACES anxiety from baseline (mean=1.5; SD=1.1) to during VR (mean=0.7; SD=0.9). No emergence delirium was reported (PAED: mean=0) and induction compliance was high (ICC: mean=0.7/10; SD=2.0).

Conclusions

Overall, VR was a suitable intervention to help youth cope in the peri-operative setting. Areas meriting further development are the timing of initiation of VR in the pre-operative waiting room to minimize interruptions, optimization of the duration of VR before OR, and optimization of induction mask fit under the headset.

References

1. Tas FQ, van Eijk CAM, Staals LM, Legerstee JS, Dierckx B. Virtual reality in pediatrics, effects on pain and anxiety: A?systematic review and meta-analysis update. Paediatr Anaesth. 2022;32(12):1292-304.
2. Davidson AJ, Shrivastava PP, Jamsen K, Huang GH, Czarnecki C, Gibson MA, et al. Risk factors for anxiety at induction of anesthesia in children: a prospective cohort study. Paediatr Anaesth. 2006;16(9):919-27.
3. Perrott C, Lee CA, Griffiths S, Sury MRJ. Perioperative experiences of anesthesia reported by children and parents. Paediatr Anaesth. 2018;28(2):149-56.
4. Mohkamkar MB, Farhoudi FM, Alam-Sahebpour AM, Mousavi SAM, Khani SP, Shahmohammadi SB. Postanesthetic Emergence Agitation in Pediatric Patients under General Anesthesia. Iran J Pediatr. 2014;24(2):184-90.
5. Kain ZN, Wang SM, Mayes LC, Caramico LA, Hofstadter MB. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg. 1999;88(5):1042-7.
6. Fortier MA, Del Rosario AM, Rosenbaum A, Kain ZN. Beyond pain: predictors of postoperative maladaptive behavior change in children. Paediatr Anaesth. 2010;20(5):445-53.
7. Simonetti V, Tomietto M, Comparcini D, Vankova N, Marcelli S, Cicolini G. Effectiveness of virtual reality in the management of paediatric anxiety during the peri?operative period: A systematic review and meta-analysis. Int J Nurs Stud. 2022;125:104115.
8. Birckhead B, Khalil C, Liu X, Conovitz S, Rizzo A, Danovitch I, et al. Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study. JMIR Ment Health. 2019;6(1):e11973.
9. Farmer T, Robinson K, Elliott SJ, Eyles J. Developing and implementing a triangulation protocol for qualitative health research. Qual Health Res. 2006;16(3):377-94.

Presenting Author

Yu Tong Huang

Poster Authors

Yu Tong Huang, MD

Faculty of Medicine and Health Sciences, McGill University

Lead Author

Sofia Addab

Shriners Hospitals for Children-Canada

Lead Author

Gianluca Bertolizio

Lead Author

Reggie Hamdy

Lead Author

Kelly Thorstad

Lead Author

Argerie Tsimicalis

RN

Ingram School of Nursing, McGill University; Shriners Hospitals for Children-Canada

Lead Author

Topics

  • Pain in Special Populations: Infants/Children