Pediatric Distraction on Induction of Anesthesia With Virtual Reality and Perioperative Anxiolysis: A Randomized Controlled Trial

Top 100 most-cited articles on pediatric anesthesia from 1990 to 2023

Pediatric anesthesia presents greater challenges than does adult anesthesia. This bibliometric analysis aimed to analyze the top 100 most cited articles to be better understand the hot spots and prospects in pediatric anesthesia. Articles and reviews related to pediatric anesthesia were retrieved from the Web of Science Core Collection from 1990 to 2023. A bibliometric analysis of the top 100 most cited articles was also performed using information such as topics, author names, countries, institutions, publication years, and journals. A total of 32 831 articles were identified, with a total of 32 230 citations for the top 100 articles. The peak period for pediatric anesthesia research was from 2005 to 2009. The USA has emerged as the most active country in pediatric anesthesia research. Major journals published included Anesthesia and Analgesia, Anesthesiology, and Pediatrics, underscoring their authority in the field. Clinical studies on the top 100 most cited articles have focused on different stages of the perioperative period, the use of different anesthetic agents, and adverse outcomes in pediatric patients. The current study conducted a bibliometric analysis of the top 100 most cited articles in the field of pediatric anesthesia. Such insights are valuable for identifying research hot spots, assessing academic impact and collaboration in pediatric anesthesia, and guiding future research directions.

Effect of video-based interventions on emergence delirium in pediatric patients: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Emergence delirium is frequently observed in pediatric patients. With advancements in video-based interventions, such as cartoons, video games, and virtual reality, these modalities may contribute to a reduced incidence of emergency delirium among children. However, robust evidence supporting their efficacy remains necessary.

METHODS

The authors conducted a systematic search across multiple databases, including Embase, MEDLINE, and Cochrane Library, to identify all randomized controlled trials comparing video-based interventions with control treatments in pediatric emergence delirium. Data were aggregated and analyzed using Review Manager 5.4 to evaluate the effectiveness of video-based interventions.

RESULTS

The analysis included eight randomized controlled trials comprising 872 children. The intervention group showed a trend toward lower Pediatric Anesthesia Emergence Delirium scores (p = 0.10) and fewer emergence delirium events (p = 0.52). Seven studies demonstrated that video-based interventions significantly reduced preoperative anxiety, as indicated by decreased scores on the modified Yale Pre-operative Anxiety Scale (p < 0.00001). Anesthesia duration did not significantly differ between the intervention and control groups (p = 0.16). Notably, subgroup analyses revealed a significant reduction in Pediatric Anesthesia Emergence Delirium scores among children under seven years of age (p = 0.001).

CONCLUSIONS

Video-based interventions were linked to lower Pediatric Anesthesia Emergence Delirium scores and a decreased incidence of emergence delirium events. However, these results did not reach statistical significance across the broader sample. Notably, in children under seven, these interventions significantly reduced the scores.

LEVEL OF EVIDENCE

III.

Can pre-visit exposure to virtual tours of healthcare facilities help reduce child and parent anxiety during outpatient surgical procedures?

AIM

The study aims to evaluate the impact of exposure to a highly realistic virtual facility tour prior to the on-site visit on patients and their parent/care partner's self-reported anxiety and physiological measures on the day of the procedure.

BACKGROUND

Preoperative anxiety impacts pediatric surgical outcomes; therefore, it is important for healthcare providers to address and manage preoperative anxiety in pediatric patients to promote better outcomes and overall wellbeing. Providing patients with a preview of the care setting before the actual procedure can be highly beneficial in mitigating preoperative anxiety.

METHODOLOGY

In this pilot randomized experimental study, sixteen patient-care partner dyads scheduled to undergo a gastrointestinal procedure either received a virtual tour identical to the places experienced on the day of the procedure (experimental group) or received no virtual tour (control group). Self-reported measures of anxiety were collected from participants before and on the day of the procedure. Physiological measures of heart rate variability and skin conductance were collected on the day of the procedure from both groups.

RESULTS

There were no significant differences between the self-reported and physiological measures of anxiety between the child groups. However, parents in the control group reported lower levels of anxiety and demonstrated lower levels of stress based on their physiological measures.

CONCLUSION

Exposure to virtual facility tours days before the surgery was not helpful in positively impacting the psychological measures related to preoperative anxiety levels for the participants.

3-Dimensional Virtual Reality Versus 2-Dimensional Video for Distraction During the Induction of Anesthesia in Children to Reduce Anxiety: A Randomized Controlled Trial

BACKGROUND

Preoperative anxiety is common in children. It can contribute to negative experiences with anesthetic induction and may cause adverse physiological and psychological effects. Virtual reality (VR) and electronic tablet devices are 2 audiovisual distraction tools that may help to reduce anxiety and enhance the preoperative experience. This study aimed to compare the use of an immersive 3-dimensional (3D) VR to 2-dimensional (2D) video on anxiety in children during induction of general anesthesia.

METHODS

Two hundred children (4-13 years) undergoing elective or emergency surgery under general anesthesia were enrolled in this randomized, controlled trial. Participants were randomized to use either the 3D VR goggles (intervention) or 2D video tablet (control) during anesthetic induction. Anxiety, the primary outcome, was measured using the modified Yale Preoperative Anxiety Scale Short Form (mYPAS-SF) at 2 time points: in the preoperative holding area before randomization (T1) and during induction of general anesthesia (T2). The primary outcome was analyzed using a linear regression model, including demographic and other covariates, to investigate any differences in anxiety scores. Secondary outcomes included evaluating compliance during the anesthetic induction (Induction Compliance Checklist), emergence of delirium (Cornell Assessment of Pediatric Delirium), perceived usefulness of the device, and child satisfaction.

RESULTS

Participant characteristics were similar between the 3D VR (n = 98) and 2D video (n = 90) groups, with a mean (±standard deviation) age 8. 8 ± 2.8 years. The median (lower quartile, upper quartile) mYPAS-SF scores for the 3D VR group at the preoperative holding area were 22.9 (22.9, 35.4), then 29.2 (24.0, 41.7) during induction. For the 2D Video group, the scores were 27.1 (22.9, 35.4) and then 30.2 (22.9, 41.1). No significant difference was observed in the increase in mYPAS-SF scores between groups (P = .672). Children in the 3D VR group were less likely to be rated as having a perfect induction (P = .039). There was no evidence of a difference between the groups in emergence delirium. Both devices were rated highly for usefulness and patient satisfaction. Children preferred VR, while anesthesiologists and parents felt the 2D was more useful.

CONCLUSIONS

This randomized controlled trial demonstrated that preoperative anxiety was equally low and induction compliance high with both 3D VR and 2D video distraction in children with parental presence during anesthetic induction.

Psychological intervention based on social cognitive theory: Treating pain, anxiety, and depression in perioperative patients

BACKGROUND

Surgery is an effective method for treating certain diseases. Factors such as disease, preoperative fear and tension, surgical stress, postoperative pain, and related complications directly affect the smooth progression and outcome of surgery. Patients may experience a series of psychological and physiological changes during the perioperative period, resulting in anxiety and depression, which may reduce the pain threshold and worsen their prognosis.

AIM

To investigate the effects of a psychological intervention among perioperative patients, based on social cognitive theory (SCT).

METHODS

We enrolled 200 patients who underwent surgical care at The First People's Hospital of Lin'an District, Hangzhou between January and December 2023. They were categorized into a routine intervention group (n = 103) and a psychological intervention group (n = 97), based on the intervention strategies used. Various assessment tools, including the self-rating anxiety scale (SAS), the self-rating depression scale (SDS), and the Connor-Davidson Resilience scale, were used to measure patients' negative states and emotions. The pre- and post-intervention scores for these metrics in the two groups were then analyzed.

RESULTS

In the psychological intervention group, the SAS and SDS scores (31.56 ± 5.18 and 31.46 ± 4.57, respectively) were significantly reduced compared to the routine intervention group (P < 0.05). The visual analog scale pain scores at 12 and 24 hours after intervention (6.85 ± 1.21, 4.24 ± 0.72) were notably higher than those in the routine intervention group (P < 0.05). The psychological intervention group also demonstrated superior scores in perseverance (36.08 ± 3.29), self-reliance (22.63 ± 2.91), optimism (11.42 ± 1.98), and resilience (70.13 ± 5.37), compared to the routine intervention group (P < 0.05). Additionally, the psychological intervention group's confrontation score (23.16 ± 4.29) was higher (P < 0.05). This group also reported lower scores in avoidance (9.28 ± 1.94) and yielding (6.19 ± 1.92) (P < 0.05). Lastly, the Short Form 36 Health Survey scores were significantly higher in the psychological intervention group, indicating a better quality of life (P < 0.05).

CONCLUSION

Psychological intervention measures based on SCT can effectively alleviate pain, anxiety, and depression in perioperative patients.

Immersive Virtual Reality for Pain and Anxiety Management Associated with Medical Procedures in Children and Adolescents: A Systematic Review

(1) Objectives: The purpose of this study was to investigate the studies that evaluate the effectiveness of immersive virtual reality (VR) as a distraction technique for pain and anxiety associated with medical procedures in children and adolescents. (2) The methods involved a systematic review of randomized controlled trials retrieved from databases in health sciences (Pubmed, CINHAL, Scopus, WOS, ProQuest, Cuiden Plus, InDICEs-CSIC). PRISMA guidelines were followed. (3) Results: Twelve trials were included. Four involved venipuncture, four involved surgical procedures, one involved vaccination, one involved burn care, one involved secondary wound closure, and the last one involved subcutaneous port access. (4) Discussion: Children who undergo medical procedures often experience pain and anxiety, which affects their physical condition and their relationships with caregivers and health professionals. Immersive VR is an effective alternative to medications to help in these cases. No author found statistically significant differences against the use of VR for distraction and palliation of pain and anxiety, which seems to be more effective at a younger age. It is important to personalize the immersive VR experience and equipment. (5) Conclusions: VR, when used with analgesics and anesthetics, appears effective in managing pain and distress caused by medical procedures.

The Effect of Using Virtual Reality During Burn Dressing on Pain, Anxiety and Fear Felt in Children: A Randomized Controlled Trial

This study was conducted to determine the effect of using virtual reality (VR) during burn dressing on the level of fear, anxiety, and pain that children would experience. This randomized controlled trial was conducted in a pretest-posttest design. Randomization of the participants (n = 65) was performed with the block randomization method. Then, 33 children were included in the intervention and 32 children in the control group with simple sequential randomization. The study data were collected using the "Family and Child Personal Information Form," "Physiological Parameters Registration Form," "Wong-Baker Faces Pain Scale," "Children's Fear Scale," and "Children's Anxiety Meter-State." The chi-square test, t-test, Shapiro-Wilk, mean, and percentile distributions were used for the data analysis. After dressing, the physiological parameters of the children who used VR were found to be within normal limits (HR: 108.48 ± 12.43, O2: 98.39 ± 1.14) compared to the children who did not use (HR: 117.38 ± 15.25, O2: 97.81 ± 1.35) (P < .05). After the dressing, children using VR (0.85 ± 1.23) were determined to have less fear than those who did not use them (3.03 ± 1.06), and similarly, children who used VR (2.64 ± 2.73) experienced less anxiety than those who did not use them (5.84 ± 2.26). When the pain levels were evaluated, the VR group (1.79 ± 2.04) was reported to feel less pain compared to the control group (5.50 ± 2.36). The VR used by children aged 5-10 years during burn dressing has been found to affect their physiological parameters and is effective in reducing fear, anxiety, and pain levels.

Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI)

BACKGROUND

Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others.

AIMS

To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology.

METHODS

An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method.

RESULTS

Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability.

CONCLUSIONS

This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.

Effective dose of intranasal remimazolam for preoperative sedation in preschool children: a dose-finding study using Dixon's up-and-down method

Background

Most preschool children are distressed during anesthesia induction. While current pharmacological methods are useful, there is a need for further optimization to an "ideal" standard. Remimazolam is an ultra-short-acting benzodiazepine, and intranasal remimazolam for pre-induction sedation may be promising.

Methods

This study included 32 preschool children who underwent short and minor surgery between October 2022 and January 2023. After pretreatment with lidocaine, remimazolam was administered to both nostrils using a mucosal atomizer device. The University of Michigan Sedation Score (UMSS) was assessed for sedation 6, 9, 12, 15, and 20 min after intranasal atomization. We used Dixon's up-and-down method, and probit and isotonic regressions to determine the 50% effective dose (ED50) and 95% effective dose (ED95) of intranasal remimazolam for pre-induction sedation. Results: Twenty-nine pediatric patients were included in the final analysis. The ED50 and ED95 of intranasal remimazolam for successful pre-induction sedation, when processed via probit analysis, were 0.65 (95% confidence interval [CI], 0.59-0.71) and 0.78 mg/kg (95% CI, 0.72-1.07), respectively. In contrast, when processed by isotonic regression, they were 0.65 (95% CI: 0.58-0.72 mg/kg) and 0.78 mg/kg (95% CI: 0.69-1.08 mg/kg), respectively. At 6 min after intranasal remimazolam treatment, 81.2% (13/16) of "positive" participants were successfully sedated with a UMSS ≧ 1. All the "positive" participants were successfully sedated within 9 min.

Conclusion

Intranasal remimazolam is feasible for preschool children with a short onset time. For successful pre-induction sedation, the ED50 and ED95 of intranasal remimazolam were 0.65 and 0.78 mg/kg, respectively.

Effectiveness of applied and casual games for young people's mental health: A systematic review of randomised controlled studies

Many youth experience mental health problems and digital games hold potential as mental health interventions. This systematic review provides an overview of randomised controlled studies assessing the effectiveness of digital applied and casual games for improving mental health in youth aged 6-24 years. A systematic search of PsycINFO, Web of Science and Pubmed yielded 145 eligible studies. Studies on (sub)clinical participant samples (n = 75) most often focused on attention-deficit/hyperactivity disorder (ADHD), autism and anxiety. Applied games were found most effective for improving social skills, verbal memory and anxiety, whereas casual games were found most effective for improving depression, anxiety and ADHD. Studies involving healthy youth (n = 70) were grouped into papers examining anxiety in medical settings, momentary effects on positive and negative affect, and papers employing a longitudinal design measuring mental health trait outcomes. Promising results were found for the use of games as distraction tools in medical settings, and for applied and casual games for improving momentary affect. Overall, our findings demonstrate the potential of digital games for improving mental health. Implications and recommendations for future research are discussed, such as developing evaluation guidelines, clearly defining applied games, harmonising outcome measures, including positive outcomes, and examining nonspecific factors that may influence symptom improvement as well.

Preoperative anxiety management in pediatric patients: a systemic review and meta-analysis of randomized controlled trials on the efficacy of distraction techniques

Background

This study addresses the pervasive issue of heightened preoperative anxiety in healthcare, particularly among pediatric patients. Recognizing the various sources of anxiety, we explored both pharmacological and nonpharmacological interventions. Focusing on distraction techniques, including active and passive forms, our meta-analysis aimed to provide comprehensive insights into their impact on preoperative anxiety in pediatric patients.

Methods

Following the PRISMA and Cochrane guidelines, this meta-analysis and systematic review assessed the efficacy of pharmaceutical and distraction interventions in reducing pain and anxiety in pediatric surgery. This study was registered on PROSPERO (CRD42023449979).

Results

This meta-analysis, comprising 45 studies, investigated pharmaceutical interventions and distraction tactics in pediatric surgery. Risk of bias assessment revealed undisclosed risks in performance and detection bias. Distraction interventions significantly reduced preoperative anxiety compared to control groups, with notable heterogeneity. Comparison with Midazolam favored distraction techniques. Subgroup analysis highlighted varied efficacies among distraction methods, with a notable reduction in anxiety levels. Sensitivity analysis indicated stable results. However, publication bias was observed, suggesting a potential reporting bias.

Conclusion

Our study confirms distraction techniques as safe and effective for reducing pediatric preoperative anxiety, offering a valuable alternative to pharmacological interventions.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=449979, PROSPERO [CRD42023449979].

The effect of augmented reality on preoperative anxiety in children and adolescents: A randomized controlled trial

BACKGROUND AND AIMS

Virtual reality has been shown to be an effective non-pharmacological intervention for reducing anxiety of pediatric patients. A newer immersive technology, that of augmented reality, offers some practical advantages over virtual reality, and also seems to show beneficial effects on anxiety. The main objective of this study was to determine whether augmented reality could reduce preoperative anxiety in pediatric patients undergoing elective day surgeries. A secondary outcome was to document the level of satisfaction from pediatric patients toward augmented reality intervention.

METHODS

Children and adolescents aged between 5 and 17 years old scheduled for elective day surgery under general anesthesia were randomly divided into two groups. Patients in the control group received standard care, whereas patients in the augmented reality group were accompanied by two virtual characters who taught them relaxation techniques and provided emotional and informational support. Anxiety was measured at the time of admission and at the time of induction using the short version of the modified Yale Preoperative Anxiety Scale.

RESULTS

The analysis included 37 pediatric patients in the augmented reality group and 64 in the control group. Anxiety scores were statistically significantly lower in the augmented reality group than those in the control group at the time of admission (median difference [95% CI]: 6.3 [0-10.4], p = .01), while no difference was observed between groups at the time of induction (median difference [95% CI]: -4.2 [-5.2-4.2], p = .58). Most patients in the augmented reality group wished to wear the glasses again and reported to be very satisfied with the intervention.

CONCLUSION

To our knowledge, this study is the first large randomized controlled trial to provide empirical evidence of reduction in anxiety for children and adolescents using augmented reality prior to induction of general anesthesia.

It's time to stop using nitrous oxide for pediatric mask induction

BACKGROUND

Mask induction of anesthesia for pediatric patients has included the use of nitrous oxide since the inception of pediatric anesthesia. However, the use of nitrous oxide precludes adequate preoxygenation. Additionally, pediatric physiology (less Functional Residual Capacity, higher oxygen consumption), increased risk of laryngospasm and lack of intravenous access increase the risk of a severe airway complication in the event of airway occlusion. Nitrous oxide does not facilitate tranquil mask placement on an unwilling child and does not meaningfully speed mask induction. Exposure to nitrous oxide has potential occupational health concerns and nitrous oxide has significant environmental detriment.

CONCLUSION

Utilizing other, evidence-based, techniques to facilitate tranquil mask placement will assure that patients have a pleasant induction experience and avoiding nitrous oxide will reduce the environmental impact, as well as improve the safety of, pediatric mask induction.

Nature-based mindfulness programs using virtual reality to reduce pediatric perioperative anxiety: a narrative review

Over 75% of pediatric surgery patients experience preoperative anxiety, which can lead to complicated recoveries. Current interventions are less effective for children over 12 years old. New interventions, like mindfulness-based ones (MBIs), are needed to address this issue. MBIs work well for reducing mental health symptoms in youth, but they can be challenging for beginners. Virtual reality (VR) nature settings can help bridge this gap, providing an engaging 3-D practice environment that minimizes distractions and enhances presence. However, no study has investigated the combined effects of mindfulness training in natural VR settings for pediatric surgery patients, creating a significant gap for a novel intervention. This paper aims to fill that gap by presenting a narrative review exploring the potential of a nature-based mindfulness program using VR to reduce pediatric preoperative anxiety. It begins by addressing the risks of anxiety in children undergoing surgery, emphasizing its impact on physical recovery, and supporting the use of VR for anxiety reduction in hospitals. The review then delves into VR's role in nature and mindfulness, discussing theoretical concepts, clinical applications, and effectiveness. It also examines how the combination of mindfulness, nature, and VR can create an effective intervention, supported by relevant literature. Finally, it synthesizes the existing literature's limitations, findings, gaps, and contradictions, concluding with research and clinical implications.

Effect of an educational video about ERAS on reducing preoperative anxiety and promoting recovery

Video propaganda is reported effectively improving patients' understanding of operation. However, whether a video introducing patients' most concerns can reduce preoperative anxiety and promote recovery stays unsealed. In this study, we investigated the effects of complementary therapy of educational video during preoperative visit. The results showed that thirty-five (23.2%) parents in Group Control were diagnosed as anxiety according to SAS, and nineteen (12.3%) patients were diagnosed after video intervention. The APAIs anxiety score and APAIs information score in Group Video were lower than those in Group Control. Compared with Group Control, video visit helped to increase the first-attempt pass rate of the knowledge retention exam and solve the patient's most worried concerns, and decrease incidence of emergence agitation, total cost of hospitalization and length of hospital stay. Moreover, video visit improved satisfaction degrees of patients and their main family members. Briefly, our study demonstrated video visit can improve patients' knowledge of anesthesia and decrease their preoperative anxiety, which may represent an important complementary therapy to routine preoperative visits.

Regional anaesthesia for ambulatory surgery

Regional anaesthesia (RA) has an important and ever-expanding role in ambulatory surgery. Specific practices vary depending on the preferences and resources of the anaesthesia team and hospital setting. It is used for various purposes, including as primary anaesthetic technique for surgery but also as postoperative analgesic modality. The limited duration of action of currently available local anaesthetics limits their application in postoperative pain control and enhanced recovery. The search for the holy grail of regional anaesthetics continues. Current evidence suggests that a peripheral nerve block performed with long-acting local anaesthetics in combination with intravenous or perineural dexamethasone gives the longest and most optimal sensory block. In this review, we outline some possible blocks for ambulatory surgery and additives to perform RA. Moreover, we give an update on local anaesthesia drugs and adjuvants, paediatric RA in ambulatory care and discuss the impact of RA by COVID-19.

The Impact of Virtual Reality (VR) Gaming and Casual/Social Gaming on the Quality of Life, Depression, and Dialysis Tolerance in Patients With Chronic Kidney Disease: A Narrative Review

This comprehensive narrative review aims to investigate the impact of virtual reality (VR) and social gaming on the quality of life, depression, and dialysis tolerance in patients with chronic kidney disease (CKD), a growing global health concern affecting the quality of life and increasing mortality rates. Through a combination of exercise and video games, exergaming, and digital game therapy (DGT), sedentary risks can be mitigated and therapy adherence enhanced. Despite potential side effects such as exhaustion and nausea, research indicates that virtual therapeutic games improve motivation and dialysis tolerance, and even reduce brain activity in pain-associated regions during procedures. These methods are superior to traditional distraction techniques like music, movies, and toys. Exergaming, social gaming, and VR gaming can improve various health factors including depressive symptoms, functional capacity, muscle strength, fatigue, physical activity, mental health, motivation, engagement, cognition, and overall quality of life for CKD patients. Representing a novel approach to CKD management, these interventions promote physical activity, cognitive stimulation, and social interaction. Continued research and innovation will facilitate the integration of VR-based therapies into routine CKD care.

The effect of watching videos using virtual reality during operating room transfer on the fear andanxiety of children aged 6-12 undergoing inguinal hernia surgery: A randomized controlled trial

BACKGROUND

Being in a hospital and undergoing a surgical intervention are very stressful for the children and their parents. It is critical to keep the pain, fear and anxiety of children at a minimum level during this period in order to have a better process.

PURPOSE

The aim of this study was to evaluate the effect of watching videos using virtual reality on fear and anxiety of children aged 6-12 years old during operating room transfer for inguinal hernia surgery.

METHODS

This prospective and randomized controlled study used parallel trial design guided by the CONSORT checklist. The study was conducted with two groups: the group that watch videos using virtual reality group and the control group. Data were collected using follow-up forms; the Children's State Anxiety Scale and the Children's Fear Scale.

RESULTS

Children in the virtual realty group had lower anxiety and fear scores than the children in the control group (p < 0.05). Evaluation of the in-group measurements demonstrated that the fear and anxiety scores of the children in the virtual reality group decreased after the transfer compared to that of the pre-transfer, while the children in the control group experienced higher fear and anxiety scores (p < 0.05).

CONCLUSION

Virtual reality is an effective method to reduce fear and anxiety in children aged 6-12 years old during their transfer to the operating room.

IMPLICATIONS FOR PRACTICE

Evidence-based protocol and guidelines should be developed for nonpharmacological methods such as virtual reality for procedural fear and anxiety in children.

The Effect of Computer Tablets on the Need for Medical Anxiolysis in Children in an Ambulatory Surgical Center

Background Preoperative anxiety is common in children undergoing surgery. When anxiety is identified or suspected, there are several strategies typically used to manage it. Perhaps the most common is anxiolytic premedication or parental presence at induction. Medications such as midazolam have been associated with adverse effects, such as a slower wakeup, and require timing of administration, while parental presence can be disturbing to the parent and divert the attention of the operating room team. A more recent option is distraction via electronic tablets. The purpose of this study was to retrospectively investigate and quantify any change in the use of midazolam, the most common anxiolytic approach at our institution, and any change in the length of time in the post-anesthesia care unit (PACU) following the introduction of tablet computers to a pediatric ambulatory surgical center. Methods We conducted an IRB-approved retrospective chart review of 13,790 pediatric patients ages one to 18 undergoing outpatient elective surgeries at the University of Florida (UF) Children's Surgical Center over a five-year period. A univariate analysis was conducted using the Fisher's Exact test and interrupted time series analysis to determine differences between midazolam administration and PACU times, with interruption occurring at tablet implementation. A multivariable analysis and sensitivity analyses were performed to confirm the findings of the univariate analysis. Results On univariate analysis, tablet availability was associated with both a decreased preoperative oral midazolam administration (odds ratio (OR) 0.158, 95% confidence interval (CI): 0.140 to 0.179, P-value <0.001) and a decreased PACU length of stay (-17.4 min, 95% CI: -19.6 to -15.3 min, P-value <0.001). The association with decreased preoperative midazolam administration held after multivariable analysis (adjusted OR 0.207, 95% CI: 0.154 to 0.278, P-value <0.001), but PACU length of stay was not statistically significant (-9.1 min, 95% CI: -20.6 to 2.4, P-value = 0.12). These results were confirmed on sensitivity analysis, with tablet availability continuing to be associated with decreased preoperative oral midazolam administration but not with reduced PACU length of stay. Conclusion Our results demonstrate that computer tablets were associated with a significant decrease in the frequency of midazolam administration and consequently may reduce preoperative pediatric anxiety. We did not find an associated change in PACU length of stay following the introduction of tablets. Tablets present a unique distraction alternative to chemical anxiolysis for institutions seeking to reduce medication use in pediatric patients.

Individual cartoon video for alleviating perioperative anxiety and reducing emergence delirium in children: a prospective randomised trial

BACKGROUND

Perioperative anxiety and emergence delirium (ED) in young children may cause a series of adverse events, which are worth investigating. Pharmacological treatments of anxiety and delirium remain uncertain, while non-pharmacological treatments lack personalization and pertinence.

AIMS

The aim of study was to determine whether an individual cartoon video can alleviate perioperative anxiety and reduce ED in young children undergoing adenoidectomy and tonsillectomy.

METHODS

Children between 3 and 7 years old undergoing adenoidectomy and tonsillectomy were randomly assigned to an individual cartoon video group (group V) or a control group (group C). In group V, an individual cartoon video of the child' s own choice was played throughout the whole waiting, anaesthesia induction and recovery periods. The children in group C were contacted through verbal conversation. The primary outcomes were anxiety measured by the Modified Yale Preoperative Anxiety Scale and ED assessed by the Paediatric Anaesthesia Emergence Delirium (PAED) scale. The secondary outcomes included cooperation during induction, postoperative pain and adverse events.

RESULTS

The incidence of anxiety were comparable in group V and group C at the holding area (T0) (26% vs 22%, p=0.323), but the incidence of anxiety of group V were significantly lower than those of group C at the time of entering the operating room (T1), during the induction of anaesthesia (T2) and leaving the post anaesthesia care unit (T6) (p<0.001, p<0.001, p<0.001) after intervention. The peak PAED score in group V was significantly lower than that in group C (12.00 (9.00-13.00) vs 13.50 (10.00-15.00), p=0.016). We found no significant differences in cooperation during induction, postoperative pain or the incidence of adverse events between the groups (2.00 (0.00-4.00) vs 3.00 (1.25-4.00), p=0.110; F=0.059, Pgroup=0.808; 3 (7.5%) vs 4 (10), p=0.692).

CONCLUSIONS

The individual cartoon video is an effective method of reducing perioperative anxiety and alleviating ED in children.

TRIAL REGISTRATION NUMBER

ChiCTR2200062300 (https://www.chictr.org.cn/index.aspx).

Median effective dose of esketamine for intranasal premedication in children with congenital heart disease

BACKGROUND

Esketamine is commonly used as a premedication for its sedation effect. However, the proper dosage for intranasal use in children with congenital heart disease (CHD) has not been determined. This study aimed to estimate the median effective dose (ED₅₀) of esketamine for intranasal premedication in children with CHD.

METHODS

Thirty-four children with CHD who needed premedication in March 2021 were enrolled. Intranasal esketamine was initiated at a dose of 1 mg/kg. Based on the outcome of sedation in the previous patient, the dose for the subsequent patient was either increased or reduced by 0.1 mg/kg, which was adjusted between each child. Successful sedation was defined as a Ramsay Sedation Scale score ≥ 3 and Parental Separation Anxiety Scale score ≤ 2. The required ED₅₀ of esketamine was calculated using the modified sequential method. Non-invasive blood pressure, heart rate, saturation of peripheral oxygen, sedation onset time, and adverse reactions were recorded at 5 min intervals after drug administration.

RESULTS

The 34 children enrolled had a mean age of 22.5 ± 16.4 (4-54) months and a mean weight of 11.2 ± 3.6 (5.5-20.5) kg; American Society of Anesthesiologists classification I-III. The ED₅₀ of intranasal S(+)-ketamine (esketamine) required for preoperative sedation in pediatric patients with CHD was 0.7 (95% confidence interval: 0.54-0.86) mg/kg, and the mean sedation onset time was 16.39 ± 7.24 min. No serious adverse events, such as respiratory distress, nausea, and vomiting were observed.

CONCLUSIONS

The ED₅₀ of intranasal esketamine was 0.7 mg/kg, which was safe and effective for preoperative sedation in pediatric patients with CHD.

TRIAL REGISTRATION

The trial was registered in the Chinese Clinical Trial Registry Network (ChiCTR2100044551) on 24/03/2021.

The impact of extended reality on surgery: a scoping review

PURPOSE

Extended reality (XR) is defined as a spectrum of technologies that range from purely virtual environments to enhanced real-world environments. In the past two decades, XR-assisted surgery has seen an increase in its use and also in research and development. This scoping review aims to map out the historical trends in these technologies and their future prospects, with an emphasis on the reported outcomes and ethical considerations on the use of these technologies.

METHODS

A systematic search of PubMed, Scopus, and Embase for literature related to XR-assisted surgery and telesurgery was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. Primary studies, peer-reviewed articles that described procedures performed by surgeons on human subjects and cadavers, as well as studies describing general surgical education, were included. Non-surgical procedures, bedside procedures, veterinary procedures, procedures performed by medical students, and review articles were excluded. Studies were classified into the following categories: impact on surgery (pre-operative planning and intra-operative navigation/guidance), impact on the patient (pain and anxiety), and impact on the surgeon (surgical training and surgeon confidence).

RESULTS

One hundred and sixty-eight studies were included for analysis. Thirty-one studies investigated the use of XR for pre-operative planning concluded that virtual reality (VR) enhanced the surgeon's spatial awareness of important anatomical landmarks. This leads to shorter operating sessions and decreases surgical insult. Forty-nine studies explored the use of XR for intra-operative planning. They noted that augmented reality (AR) headsets highlight key landmarks, as well as important structures to avoid, which lowers the chance of accidental surgical trauma. Eleven studies investigated patients' pain and noted that VR is able to generate a meditative state. This is beneficial for patients, as it reduces the need for analgesics. Ten studies commented on patient anxiety, suggesting that VR is unsuccessful at altering patients' physiological parameters such as mean arterial blood pressure or cortisol levels. Sixty studies investigated surgical training whilst seven studies suggested that the use of XR-assisted technology increased surgeon confidence.

CONCLUSION

The growth of XR-assisted surgery is driven by advances in hardware and software. Whilst augmented virtuality and mixed reality are underexplored, the use of VR is growing especially in the fields of surgical training and pre-operative planning. Real-time intra-operative guidance is key for surgical precision, which is being supplemented with AR technology. XR-assisted surgery is likely to undertake a greater role in the near future, given the effect of COVID-19 limiting physical presence and the increasing complexity of surgical procedures.

Developmentally Appropriate Care of Pediatric Patients in the Perioperative Setting

Pediatric patients do not undergo procedures exclusively at pediatric specialty facilities. Many perioperative nurses will care for a pediatric patient at some point in their career. Children and their caregivers often experience elevated levels of anxiety during the perioperative experience. Possessing knowledge of the child's age and developmental stage and using effective communication techniques can decrease this anxiety. This article presents insights into the stages of pediatric cognitive and psychosocial development and special pediatric health care considerations. Approaching and interacting with a child in a manner appropriate for their age and developmental stage can foster a more trusting nurse-child-caregiver relationship and reassure the caregiver that the perioperative team is providing their child with safe, high-quality care. Also included are five hypothetical case studies that illustrate effective communication styles and developmentally appropriate techniques that personnel can apply during the pediatric patient's perioperative experience.

Effect of a game-based intervention on preoperative pain and anxiety in children: A systematic review and meta-analysis

BACKGROUND

Games are increasingly being used as a means of alleviating pain and anxiety in paediatric patients, in the view that this form of distraction is effective, non-invasive and non-pharmacological.

AIMS

To determine whether a game-based intervention (via gamification or virtual reality) during the induction of anaesthesia reduces preoperative pain and anxiety in paediatric patients.

METHODS

A systematic review with meta-analysis of randomised controlled trials was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using RevMan software. The review was based on a search of the EMBASE, CINAHL, Medline, SciELO and Scopus databases, conducted in July 2021. No restriction was placed on the year of publication.

RESULTS

26 studies were found, with a total study population of 2525 children. Regarding pain reduction, no significant differences were reported. For anxiety during anaesthesia induction, however, a mean difference of -10.62 (95% CI -13.85, -7.39) on the Modified Yale Preoperative Anxiety Scale, in favour of game-based intervention, was recorded.

CONCLUSIONS

Game-based interventions alleviate preoperative anxiety during the induction of anaesthesia in children. This innovative and pleasurable approach can be helpful in the care of paediatric surgical patients.

RELEVANCE TO CLINICAL PRACTICE

In children, preoperative management is a challenging task for healthcare professionals, and game-based strategies could enhance results, improving patients' emotional health and boosting post-surgery recovery. Distractive games-based procedures should be considered for incorporation in the pre-surgery clinical workflow in order to optimise healthcare.

Virtual reality in pediatrics, effects on pain and anxiety: A systematic review and meta-analysis update

INTRODUCTION

Medical procedures are often accompanied by pain and anxiety in pediatric patients. A relatively new technique to reduce pediatric pain and anxiety is virtual reality. Virtual reality is both applied as a distraction tool and as an exposure tool to prepare patients for medical procedures. Research into the application of virtual reality in medical settings is rapidly evolving. This meta-analysis is an update of the meta-analysis of Eijlers et al. investigating the effectiveness of virtual reality as an intervention tool on pain and anxiety in pediatric patients undergoing medical procedures.

METHODS

We searched the databases Embase, Medline, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and PsycINFO. For each of these databases, different search strategies were developed. The search period from the meta-analysis from Eijlers et al., reaching until April 2018, was extended to December 2020. Pain and anxiety outcomes during medical procedures were compared for virtual reality and standard care conditions for various medical procedures.

RESULTS

The search yielded 1824 articles, of which 13 met our inclusion criteria. Combined with 13 articles of Eijlers' review study, this resulted in 26 articles. Virtual reality was applied as distraction (n = 23) during medical procedures or as exposure (n = 4) before medical procedures. The effect of virtual reality distraction was mostly studied in patients during venous access (n = 10). The overall weighted standardized mean difference for virtual reality distraction was -0.67 (95% CI, -0.89 to -0.45; p < .001) on patient-reported pain (based on 21 studies) and -0.74 (95% CI, -1.00 to -0.48; p < .001) on patient-reported anxiety (based on 10 studies). The effect of virtual reality as an exposure tool on patient-reported anxiety was significant too (standardized mean difference = -0.58; 95% CI, -1.15 to -0.01; p < .05).

DISCUSSION

The current updated systematic review and meta-analysis indicates that virtual reality is a useful tool to reduce pain and anxiety in pediatric patients undergoing a range of medical procedures as it significantly decreases pain and anxiety outcomes when compared to care as usual.

The Impact of Scripted Self-Hypnotic Relaxation on the Periprocedural Experience and Anesthesiologist Sedation Use in the Pediatric Cardiac Catheterization Suite: A Prospective Randomized Controlled Trial

Purpose

To assess the impact on children of self-hypnotic relaxation scripts read by trained staff prior to the induction of anesthesia and/or extubation on the periprocedural experience.

Patients and Methods

A total of 160 children aged 7–18 years undergoing a cardiac catheterization intervention under general anesthesia were randomized into 4 groups: (1) a pre-procedure (PP-script) read prior to entering the procedural room, (2) a script read prior to extubation (PX-Script), (3) both PP- and PX-Scripts read and (4) no script read. Anxiety and pain were rated on self-reported 0–10 scales. The modified Yale Preoperative Anxiety Scale was used for preoperative anxiety. The effect of script reading was associated with outcomes by linear regression for continuous variables, and logistic regression for binary variables in two-sided tests at a significance level of 0.05. Results are given in odds ratios (OR) and 95% confidence intervals (CI).

Results

Data were available for 158 patients. Reading the PP-Script prior to anesthesia was associated with a significant reduction in the use of intraoperative sedatives from 30% to 14% (OR 0.40; CI 0.18–0.88; p = 0.02) by the anesthesiologists, who were blinded to group attribution until extubation. This was despite the children not self-reporting significantly lower levels of anxiety or pain. The PX-Script did not change outcomes. Among groups, there was no significant difference in room time, postoperative recovery time and pain.

Conclusion

Reading a PP-Script for guidance in self-hypnotic relaxation can result in less need for intravenous sedation in the judgment of the anesthesiologist, independent of the children’s self-reported anxiety and pain. This raises interesting questions about subconscious patient–physician interactions affecting pain management.

Clinicaltrials.gov Identifier

NCT02347748.

A Systematic Review of Randomized Controlled Trials on Virtual Reality Application in Pediatric Patients

Virtual reality is a novel approach for distracting and alleviating anxiety, pain, and other complications during medical procedures, and it can be more effective than conventional methods. In virtual reality, the patient is completely immersed in the virtual environment, which is used to make patients feel more comfortable and can provide a positive prognosis. The data were searched by using the Boolean operator "AND" between the search phrases "Virtual reality," and "Pediatrics" and the relevant literature was extracted. The inclusion criteria were the free full text, randomized controlled trials, studies between 2016 and 2022 and pediatric patients. This systematic review was conducted to compare randomized controlled trials of virtual reality applications in pediatric patients in different clinical settings. Of the included 15 randomized controlled trials, 12 studies were on pain and anxiety, two on brain injury and cerebral palsy, and one on awareness among asthmatic patients. This review concluded that virtual reality exposure has a beneficial effect on pediatric patients in reducing pain and anxiety, improving muscle strength and dexterity, and awareness among asthmatic patients.

The involvement and autonomy of young children undergoing elective paediatric cardiac surgery: a qualitative study

Background

Standards generally reported in the literature about informing children and respecting their consent or refusal before elective heart surgery may differ from actual practice. This research aims to summarize the main themes in the literature about paediatric anaesthesia and compare these with research findings on how health professionals counsel young children before elective heart surgery, respect their consent or refusal, and maintain patient-centred care.

Methods

This qualitative research involved: literature reviews about children’s consent to surgery and major interventions; observations of wards, clinics and medical meetings in two paediatric cardiology departments, October 2019 to February 2020; audio-recorded semi-structured interviews with 45 hospital staff, including 5 anaesthetists, and related experts, November 2019 to April 2021; interviews with 16 families, with children aged 6- to 15-years and their parents shortly after elective heart surgery, and some months later (reported in other papers); thematic data analysis; and research reports on how different professions contribute to children’s informed decisions for heart surgery.

Results

The medical, ethics and English legal literature tend to assume legal minors cannot refuse major recommended treatment, and cannot consent until they are 12 years or older. Little is said about informing pre-competent children. If children resist, some anaesthetists rely on sedation and distraction, and avoid much informed discussion, aiming to reduce peri-operative anxiety. However, interviewees reported informing young children, and respecting their consent or refusal before elective surgery. They may delay elective surgery and provide further information and support, aiming to reduce fear and promote trust. Six years of age was commonly cited as the threshold for respecting consent to heart transplantation.

Conclusion

Differing views about younger children’s competence, anxiety and best interests support different reactions to children’s consent and refusal before elective heart surgery. This paper reports the zero-restraint policy followed for over a decade in at least one leading surgery centre. The related law and literature need to be updated, to take more account of evidence of actual practice.

A gamified mobile health intervention for children in day surgery care: Protocol for a randomized controlled trial

AIMS

To describe a study protocol for a randomized controlled trial which will evaluate the effectiveness of a gamified mobile health intervention for children in whole day surgery care.

DESIGN

A study protocol for a two-arm randomized controlled trial.

METHODS

Participants will be randomly assigned to the intervention group (N = 62), in which patients receive routine care and play a mobile game designed for children or the control group (N = 62), in which patients receive routine care, including a mobile phone application that supports parents during the care path. The primary outcome is children's pre-operative anxiety, while the secondary outcome measures included fear and postoperative pain, along with parental satisfaction and anxiety. Data collection started in August 2020.

RESULTS

The results of the ongoing randomized controlled trial will determine whether the developed gamified mobile health intervention can be recommended for hospital use, and whether it could be used to educate children about their surgical treatment to decrease anxiety.

Smartphone Interventions Effect in Pediatric Subjects on the Day of Surgery: A Meta-Analysis

Background: A meta-analysis was performed to evaluate the effect of smartphone interventions on the anxiety of the pediatric subjects at induction on the day of surgery compared to oral midazolam or standard care as control. Methods: A systematic literature search up to June 2021 was performed and nine studies selected 785 pediatric subjects on the day of surgery at the start of the study; 390 of them were using smartphone interventions, 192 were control, and 203 were using oral midazolam. They were reporting relationships between the effects of smartphone interventions on the anxiety of the pediatric subjects at induction on the day of surgery compared to oral midazolam or control. The mean difference (MD) with its 95% CIs was calculated to assess the effect of smartphone interventions on the anxiety of the pediatric subjects at induction on the day of surgery compared to oral midazolam or control using the continuous method with a fixed or a random-effects model. Results: Smartphone interventions in pediatric subjects were significantly related to lower anxiety at induction on the day of surgery (MD, -19.74; 95% CI, -29.87 to -9.61, p < 0.001) compared to control and significantly related to lower anxiety at induction on the day of surgery (MD, -7.81; 95% CI, -14.49 to -1.14, p = 0.02) compared to oral midazolam. Conclusion: Smartphone interventions in pediatric subjects on the day of surgery may have lower anxiety at induction compared to control and oral midazolam. Further studies are needed to confirm these findings.

Intraoperative virtual reality distraction in TKA under spinal anesthesia: a preliminary study

INTRODUCTION

The effect of patient anxiety during the perioperative period has been shown to be of great importance in its influence on post-operative recovery. Over the last 10 years, virtual reality (VR) has been developed in anesthesia for patient's distraction by immersion. The aim of this study was to evaluate post-operative patient anxiety the day after TKA surgery under spinal anesthesia (SA) with or without VR distraction.

MATERIALS AND METHODS

A single-center, prospective cohort study was performed looking at patients undergoing TKA surgery under SA with a VR headset (group 1) compared with those undergoing the same procedure with standard protocol (group 2). Data using a validated scoring system looking at patient anxiety (STAI Y-1) were collected. Secondary endpoints were need for sedation during surgery, intraoperative complications (hypotension and oxygen need), postoperative pain and comfort scores (VAS) and patient satisfaction.

RESULTS

Ten patients (group 1) received the VR headset during surgery and 10 (group 2) received the standard protocol established in our center. Average age was 73 years old. No difference was found in post-operative patient anxiety regarding to STAI Y-1 score (95% CI - 7 to 10, p = 0.71. There was a decrease of sedation and intra-operative adverse event as hypotension and oxygen requirement in group 1 (p < 0.0001, p = 0.015, p = 0.0054), and a significant increase in comfort score (p = 0.002). No difference in patient satisfaction was found.

CONCLUSION

Using VR for immersive distraction seemed to lead to no difference in patient anxiety in TKA under SA. Intra-operative adverse events were decreased, and post-operative comfort was increased. Patient satisfaction was not modified. This preliminary study is encouraging and gives us arguments to involve larger number of patients while exploring the various possibilities offered by VR.

Effectiveness of virtual reality in the management of paediatric anxiety during the peri‑operative period: A systematic review and meta-analysis

BACKGROUND

Children undergoing surgery generally experience anxiety during the perioperative period, which could impact the surgical outcome, cause long-term psychological consequences and result in later healthcare avoidance. Preoperative anxiety in children is managed using both pharmacological and non-pharmacological therapies. The latter include distraction, a tour of the operating room and parental presence until the induction of anaesthesia. A novel and effective non-pharmacological therapies is the use of virtual reality to reduce anxiety and pain in children scheduled for medical procedures. However, the effectiveness of virtual reality in paediatric surgery has yet to be evaluated in a systematic review.

OBJECTIVE

To evaluate the effectiveness of virtual reality in the management of anxiety in paediatric patients during the perioperative period.

DESIGN

Both a systematic review and a meta-analysis of randomised controlled trials were performed according to the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions Section 8.5 and in accordance with the Cochrane Effective Practice and Organisation of Care. The results are reported as prescribed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

DATA SOURCES

A systematic search of randomised controlled trials was conducted using Medline, SCOPUS, Web of Science, Ovid MEDLINE and CINAHL.

REVIEW METHODS

Two researchers screened potentially eligible articles and then assessed the quality of the reported studies using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions Section 8.5 and according to Cochrane Effective Practice and Organisation of Care. The data were synthesised using the random-effects models to incorporate the estimated heterogeneity in the weighting. Heterogeneity was tested using the Q and I² statistics. The τ² statistic, an estimate of the amount of variation between the included studies, was also determined. Studies whose heterogeneity with respect to primary outcome measurements hindered pooling of the results for meta-analysis were summarised narratively.

RESULTS

Seven studies were eligible for inclusion in this systematic review. An effect size for anxiety could be determined in six. The results support the effectiveness of virtual reality in reducing anxiety in paediatric patients undergoing elective surgery. The overall effect was supported by a confidence interval < 0 (PL = -0.341, 95% confidence interval: -0.620 to -0.107) and by heterogenity indexes that were non significant (Q = 9.49, p = 0.091) or not important (I² = 38.64%).

CONCLUSIONS

Paediatric patients undergoing elective surgery may benefit from virtual reality as a distraction method that can reduce anxiety. PROSPERO register, number: (blinded for Referee).

An update on pediatric sedation techniques in nonoperating room locations

PURPOSE OF REVIEW

To review advancements in care for pediatric patients in nonoperating room settings.

RECENT FINDINGS

Advances in patient monitoring technology, utilization of Child Life specialists, and alternative staffing models are helping anesthesia providers meet the rising demand for coverage of pediatric nonoperating room anesthesia (NORA) cases. The Wake Up Safe and Pediatric Sedation Research Consortium registries are exploring outcome measures regarding the safety of pediatric anesthesia in off-site locations and have reported an increased risk for severe respiratory and cardiac adverse events when compared to OR anesthesia sites. Additionally, malpractice claims for NORA have a higher proportion of claims for death than claims in operating rooms.

SUMMARY

Pediatric NORA requires thorough preparation, flexibility, and vigilance to provide safe anesthesia care to children in remote locations. Emerging techniques to reduce anesthetic exposure, improve monitoring, and alternative staffing models are expanding the boundaries of pediatric NORA to provide a safer, more satisfying experience for diagnostic and interventional procedures.

Patient Satisfaction Through an Immersive Experience Using a Mobile Phone-Based Head-Mounted Display During Arthroscopic Knee Surgery Under Spinal Anesthesia: A Randomized Clinical Trial

BACKGROUND

Patient satisfaction is an important element of high-quality health care. Virtual reality has been studied for its sedative and analgesic effects, as it immerses the patient into an artificial interactive environment. Deriving from this concept, we hypothesized that an immersive experience that engulfs the senses with noninteractive visual and auditory stimuli would have a positive effect on satisfaction and anxiety in patients undergoing spinal anesthesia.

METHODS

We enrolled and randomized 90 patients undergoing spinal anesthesia for arthroscopic knee surgery into an immersive experience arm and an intravenous midazolam sedation arm. The immersive experience was provided through a mobile phone-based head-mounted display showing binocular monoscopic video and noise-canceling headphones playing audio. The primary outcome measure was postoperative satisfaction, measured using a visual analog scale and compared using the Mann-Whitney U test; secondary outcomes included anxiety score (measured using the 6-item State-Trait Anxiety Inventory), hemodynamic stability, and additional sedative requirement.

RESULTS

The visual analog scale satisfaction score with immersive experience was significantly higher than with midazolam (median [interquartile range {IQR}] of 93 [82-98] and 80 [73-93], respectively, P = .004), with Hodges-Lehmann median difference estimate of 7 (95% confidence interval, 3-14). The change in anxiety scores from the preoperative to postoperative period between the groups was not significantly different (P = .08), with a Hodges-Lehmann median difference estimate of 3.3 (95% confidence interval, 0-6.7). All patients were hemodynamically stable, were without significant adverse events, and did not require additional sedatives.

CONCLUSIONS

We have found that an immersive experience is an effective and acceptable intraoperative alternative to pharmacological sedation in patients undergoing arthroscopic knee surgery under spinal anesthesia, with higher satisfaction levels and no detected difference in preoperative to postoperative anxiolytic effect.

State of the Art: Immersive Technologies for Perioperative Anxiety, Acute, and Chronic Pain Management in Pediatric Patients

Purpose of Review

This review summarizes and provides a comprehensive narrative synthesis of the current evidence on immersive technology’s (i.e., virtual and augmented Reality) use for perioperative anxiety, acute, and chronic pain in pediatrics.

Recent Findings

Researchers have increasingly studied immersive technology as a non-pharmacological alternative for perioperative anxiety, acute, and chronic pain management. We found several research studies published over the last 3 years: almost all studies examined the use of virtual reality for perioperative anxiety and pain; only one case report was about the use of augmented reality for preoperative anxiety. Most studies showed that virtual reality intervention is effective and safe for perioperative anxiety, acute, and chronic pain. However, the studies are heterogeneous with relatively small sample sizes.

Summary

This review shows that more high-quality studies (i.e., randomized controlled trials with larger sample sizes and standardized methods for measuring and reporting outcomes) are needed to examine the effectiveness and adverse effects of virtual reality intervention on perioperative anxiety, acute, and chronic pain in pediatrics.

Virtual reality for pediatric periprocedural care

PURPOSE OF REVIEW

Commercial availability of virtual reality headsets and software has exponentially grown over the last decade as it has become more sophisticated, less expensive, and portable. Although primarily used by the general public for entertainment, virtual reality has been adopted by periprocedural clinicians to improve patient experiences and treatments. The purpose of this review is to explore recently reported evidence for virtual reality effectiveness for pediatric periprocedural care and discuss considerations for clinical implementation.

RECENT FINDINGS

In the preprocedure setting, practitioners use virtual reality to introduce children to periprocedural environments, distract attention from preprocedural vascular access, and increase cooperation with anesthesia induction. Intraprocedure, virtual reality decreases sedation requirements, and in some instances, eliminates anesthesia for minor procedures. Virtual reality also augments pain reduction therapies in the acute and extended rehabilitation periods, resulting in faster recovery and improved outcomes. Virtual reality seems to be well treated for pediatric use, given close clinical care and carefully curated content.

SUMMARY

Given the multiple clinical applications of virtual reality to supplement pediatric periprocedural care, practitioners should consider developing clinical programs that reliably provide access to virtual reality. Future research should focus on identification of patient characteristics and types of software that yield optimal patient outcomes.

Enhancing Patient Experience in Office-Based Laryngology Procedures With Passive Virtual Reality

Objectives

Virtual reality (VR) has been used as nonpharmacologic anxiolysis benefiting patients undergoing office-based procedures. There is little research on VR use in laryngology. This study aims to determine the efficacy of VR as anxiolysis for patients undergoing in-office laryngotracheal procedures.

Study Design

Randomized controlled trial.

Setting

Tertiary care center.

Methods

Adult patients undergoing office-based larynx and trachea injections, biopsy, or laser ablation were recruited and randomized to receive standard care with local anesthesia only or local anesthesia with adjunctive VR. Primary end point was procedural anxiety measured by the Subjective Units of Distress Scale (SUDS). Subjective pain, measured using a visual analog scale, satisfaction scores, and procedure time, and baseline anxiety, measured using the Hospital Anxiety and Depression Scale (HADS), were also collected.

Results

Eight patients were randomized to the control group and 8 to the VR group. SUDS scores were lower in the VR group than in the control group with mean values of 26.25 and 53.13, respectively (P = .037). Baseline HADS scores did not differ between groups. There were no statistically significant differences in pain, satisfaction, or procedure time. Average satisfaction scores in VR and control groups were 6.44 and 6.25, respectively (P = .770). Average pain scores were 3.53 and 2.64, respectively (P = .434).

Conclusion

This pilot study suggests that VR distraction may be used as an adjunctive measure to decrease patient anxiety during office-based laryngology procedures. Procedures performed using standard local anesthesia resulted in low pain scores and high satisfaction scores even without adjunctive VR analgesia.

Level of Evidence

1

Comparison of the Effects of Visual and Auditory Distractions on Fistula Cannulation Pain among Older Patients Undergoing Hemodialysis: A Randomized Controlled Clinical Trial

Pain associated with fistula cannulation is a challenge for nurses who provide care to older patients undergoing hemodialysis. Several non-pharmacological methods have been suggested for relieving fistula cannulation pain, but the benefits of visual and auditory distraction methods among older patients undergoing hemodialysis have not been investigated yet. Therefore, this study aimed to compare the effects of visual and auditory distractions on fistula cannulation pain among older patients undergoing hemodialysis. This randomized controlled clinical trial was conducted on 120 older patients undergoing hemodialysis. They were randomly assigned to three groups of visual distraction, auditory distraction, and the control (n = 40 in each group) using a simple random assignment method. The distraction interventions continued for three consecutive sessions and the numeric rating scale of pain severity was used for data collection. Descriptive and inferential statistics were used for data analysis using SPSS. It was found that pain severity significantly reduced after the distraction interventions in either the auditory or visual distraction groups and also after all three distraction sessions (p = 0.001). However, visual distraction had a better effect on the reduction of pain severity. Therefore, while both visual and auditory distractions reduced pain severity in older patients undergoing hemodialysis, visual distraction was more effective. Nurses are encouraged to incorporate visual distraction as a safe and non-pharmacologic technique into routine nursing care for reducing older patients’ suffering and improving their wellbeing when fistula cannulation is performed.