Virtual Reality Tour to Reduce Perioperative Anxiety in an Operating Setting Before Anesthesia: Randomized Clinical Trial

An Immersive Virtual Reality Intervention for Preoperative Anxiety and Distress Among Adults Undergoing Oncological Surgery: Protocol for a 3-Phase Development and Feasibility Trial

BACKGROUND

Preoperative state anxiety (PSA) is distress and anxiety directly associated with perioperative events. PSA is associated with negative postoperative outcomes such as longer hospital length of stay, increased pain and opioid use, and higher rates of rehospitalization. Psychological prehabilitation, such as education, exposure to hospital environments, and relaxation strategies, has been shown to mitigate PSA; however, there are limited skilled personnel to deliver such interventions in clinical practice. Immersive virtual reality (VR) has the potential for greater accessibility and enhanced integration into an immersive and interactive experience. VR is rarely used in the preoperative setting, but similar forms of stress inoculation training involving exposure to stressful events have improved psychological preparation in contexts such as military deployment.

OBJECTIVE

This study seeks to develop and investigate a targeted PSA intervention in patients undergoing oncological surgery using a single preoperative VR exposure. The primary objectives are to (1) develop a novel VR program for patients undergoing oncological surgery with general anesthesia; (2) assess the feasibility, including acceptability, of a single exposure to this intervention; (3) assess the feasibility, including acceptability, of outcome measures of PSA; and (4) use these results to refine the VR content and outcome measures for a larger trial. A secondary objective is to preliminarily assess the clinical utility of the intervention for PSA.

METHODS

This study comprises 3 phases. Phase 1 (completed) involved the development of a VR prototype targeting PSA, using multidisciplinary iterative input. Phase 2 (data collection completed) involves examining the feasibility aspects of the VR intervention. This randomized feasibility trial involves assessing the novel VR preoperative intervention compared to a VR control (ie, nature trek) condition and a treatment-as-usual group among patients undergoing breast cancer surgery. Phase 3 will involve refining the prototype based on feasibility findings and input from people with lived experience for a future clinical trial, using focus groups with participants from phase 2.

RESULTS

This study was funded in March 2019. Phase 1 was completed in April 2020. Phase 2 data collection was completed in January 2024 and data analysis is ongoing. Focus groups were completed in February 2024. Both the feasibility study and focus groups will contribute to further refinement of the initial VR prototype (phase 3), with the final simulation to be completed by mid-2024.

CONCLUSIONS

The findings from this work will contribute to the limited body of research examining feasible and broadly accessible interventions for PSA. Knowledge gained from this research will contribute to the final development of a novel VR intervention to be tested in a large population of patients with cancer before surgery in a randomized clinical trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04544618; https://www.clinicaltrials.gov/study/NCT04544618.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55692.

The Effect of Preoperative Education Regarding Intraoperative Care on a Patient's Level of Fear of Surgery: A Randomized Controlled Study

This randomized controlled study aimed to investigate the effect that preoperative education provided by the perioperative nurse about the OR environment and intraoperative care has on surgical fear in patients who come to the OR for surgical intervention. The study involved 92 patients undergoing elective abdominal surgery who were randomly assigned to the intervention or routine care group. Preoperatively, patients in the intervention group received education via a form that described the OR environment, the surgical process, and intraoperative care. The patients' surgical fear levels were assessed in the patients' rooms, in the clinic before education, and on arrival to the OR after education. The results showed that preoperative education about the OR environment and intraoperative processes significantly reduced patients' surgical fears.

Clinical observation of perioperative negative emotional changes in patients with percutaneous balloon compression for primary trigeminal neuralgia: A prospective cohort study

OBJECTIVE

To investigate the prevalence of negative emotions in trigeminal neuralgia (TN) patients, to identify risk factors associated with anxiety and depression, and further to explore the impact of percutaneous balloon compression (PBC) on anxiety and depression in TN patients during the perioperative period.

METHODS

400 patients with primary TN treated with PBC at our institution from November 2021 to April 2023 were included. We analyzed visual analogue scale (VAS) and the Hospital Anxiety and Depression Scale (HADS) scores. The patients' clinical data and short-term clinical outcomes were gathered and subjected to statistical analysis.

RESULTS

This study included a total of 400 patients diagnosed with primary TN. Patients who had high pain intensity (OR 1.20, 95 % CI 1.02-1.41; p = 0.025) or a history of multiple previous TN procedures (OR 1.49, 95 % CI 1.03-2.16; p = 0.036), were more prone to anxiety. Patients who were female (OR 1.59, 95 % CI 1.03-2.44; p = 0.036), had high pain intensity (OR 1.28, 95 % CI 1.08-1.52; p = 0.004) or had a history of multiple previous TN procedures (OR 1.48, 95 % CI 1.11-1.98; p = 0.008), were more likely to have depression. Significant improvements in anxiety and depressive symptoms were observed in patients who experienced pain relief after PBC (p < 0.001).

CONCLUSIONS

Female gender, high pain intensity, and a history of multiple prior TN procedures are associated risk factors for anxiety and depression in TN patients. PBC can provide patients with a high pain relief rate and significantly improve their anxiety and depression symptoms during the perioperative period.

The surgical metaverse

Recent developments have seen acceleration in the development of virtual reality (VR) and augmented reality (AR) technology. Through these developments, the metaverse has emerged. Within the metaverse, users create an avatar to experience an immersive, interactive extended reality. Current front-runners in its implementation are the financial, communication and entertainment sectors. This technology, however, is receiving greater recognition in the medical world, with national and international surgical bodies acknowledging the benefits that VR and the metaverse will have on surgical training and patient care. Its versatility means that we are likely to see VR related technology become intimately woven into the fabric of surgery in the next two decade. In this article, the impact of the metaverse on the surgical field will be discussed.

Effectiveness of virtual reality in reducing preoperative anxiety in adults: A systematic review and meta-analysis

AIM

To evaluate the impact of a virtual reality (VR) intervention on adult patients' preoperative anxiety, heart rate, respiration rate and blood pressure.

DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs).

DATA SOURCES

A librarian-designed search of the Cochrane Library, PubMed, Web of Science, EMBASE, CINAHL, CBM, CNKI and Wanfang databases was conducted to identify research studies in English or Chinese on RCTs from their inception to 31 May 2022. Detailed search strategies and the checklist are provieded in Supplementary files S1 and S2.

REVIEW METHODS

Two researchers independently screened eligible studies. The Cochrane Handbook for Systematic Reviews of Interventions was used to assess the risk of bias in the included studies. A fixed- or random-effects meta-analysis model was used to determine the pooled mean difference based on the results of the heterogeneity test.

RESULTS

This study included 11 articles with a total of 892 participants. VR distraction comprised five studies, and VR exposure consisted of six studies. The results indicated that VR could reduce preoperative anxiety in adult patients and VR exposure seems to be more effective. The results also indicated that VR intervention can effectively reduce patients' heart rate and blood pressure compared to traditional intervention methods, but had no significant effect on respiration rate.

CONCLUSION

VR technology could relieve preoperative anxiety in adult patients through distraction or exposure. More well-designed RCTs containing a wider range of surgical types are needed to verify our findings before we can make strong recommendations.

IMPACT

Our systematic review and meta-analysis show a positive effect of VR distraction and exposure interventions in reducing preoperative anxiety in adult patients. We suggest incorporating VR into preoperative procedures as an auxiliary way to reduce negative emotions in eligible patients.

NO PATIENT OR PUBLIC CONTRIBUTION

Our paper is a systematic review and meta-analysis and such details do not apply to our work.

Patient-reported perioperative anaesthesia-related anxiety is associated with impaired patient satisfaction: a secondary analysis from a prospective observational study in Switzerland

Perioperative anxiety is common. The relationship between anxiety and patient satisfaction with anaesthesia is still under debate. We assessed the prevalence and different causes of anaesthesia-related fears leading to perioperative anxiety and its association with patient satisfaction. A multiple-time validated, psychometrically developed questionnaire assessing the presence of anxiety, causes of fear, and different dimensions of patient satisfaction was sent to patients after discharge. The clinical data were obtained from a previous study. The sample size was calculated to recruit a minimum of 300 completed questionnaires. Statistical analyses included multivariate logistic regression models. Complete data were available for 474 of the 600 patients recruited for the study (response rate: 79%). A total of 141 patients (30%) reported anxiety regarding anaesthesia before hospital admission. The prevalence of anxiety was significantly associated with patient age (< 54 years: n = 196, prevalence = 37%; > 54 years: n = 263, prevalence = 24%; p = 0.002), female sex (female: n = 242, prevalence 39%; male: n = 223, prevalence 20%; p < 0.001), and surgical speciality (gynaecology (n = 61, prevalence = 49%), otolaryngology (n = 56, prevalence = 46%); p < 0.001). Fear of not awakening from anaesthesia (n = 44, prevalence = 32%, SD 45.8) and developing postoperative nausea or vomiting (n = 42, prevalence = 30%, SD 46.0) were the most reported anaesthesia-related causes of fear. Anxiety was associated with impaired overall patient satisfaction (mean dissatisfaction score 15%, versus 23%, SD 16.3 in the anxious group, SD 16.3, p < 0.001), especially regarding the dimensions "information and involvement in decision-making" (14% of deficits stated in the non-anxious group compared to 23% in the anxious group, p < 0.001), "respect and trust" (2% vs 6.26%, p < 0.001) and "continuity of care" (50% vs 57%, p < 0.015). Patient-reported anaesthesia-related anxiety is common and may affect important outcome parameters such as patient satisfaction. Abstract presented in e-poster format at Euroanaesthesia 2023, June 3-5, Glasgow.

Relieving Anxiety Through Virtual Reality Prior to Endoscopic Procedures

PURPOSE

Endoscopic procedures can cause anxiety, which can lead to more uncomfortable, difficult, and incomplete procedures, in addition to greater use of sedative medication. Here, we investigate whether exposing patients to virtual reality (VR) prior to endoscopic procedures can reduce their anxiety levels.

MATERIALS AND METHODS

Forty patients at Gangnam Severance Hospital were enrolled and divided into the VR group and the control group. Patients in the VR group were exposed to VR prior to their procedure to alleviate anxiety. The primary data outcomes were State-Trait Anxiety Inventory (STAI), pain score, satisfaction with sedation, and satisfaction with the procedure.

RESULTS

The mean STAI-state and STAI-trait did not differ significantly between the control group and the VR group. While defining a high anxiety STAI score as ≥45 in an STAI-state, the proportion of patients with high anxiety at baseline was 35% and increased to 50% prior to the procedure in the control group. However, in the VR group, the proportion of patients with high anxiety at baseline was 60% and decreased to 50% prior to the procedure. The proportion changes of patients with high anxiety in the STAI-state exhibited a significant difference between the control and VR groups (p=0.007). Furthermore, patients' satisfaction with sedation was significantly greater in the VR group compared to the control group (p=0.017).

CONCLUSION

VR exposure may relieve patients' anxiety levels prior to endoscopic procedures, but further well-designed placebo-controlled studies are needed. VR, an inexpensive, easily available, and non-invasive method, also improved the satisfaction with sedation of endoscopic procedures.

Effects of virtual tour on perioperative pediatric anxiety

BACKGROUND

There is a high incidence of perioperative anxiety in the pediatric population, with adverse side effects, such as emergency delirium and maladaptive postoperative behaviors.

AIMS

The study's objective was to compare the level of preoperative anxiety in children after standard preparation plus a virtual tour of the operating room vs. standard preparation alone.

PATIENTS/METHODS

This was a prospective single-center, randomized, controlled, blinded trial with parallel assignment, registered as NCT04043663. Eligible subjects were healthy children (ASA I-II) aged 4-12, scheduled for outpatient surgery. Five visits were conducted during the study, two at the hospital and three over the phone. Variables assessed were child's anxiety through the modified Yale Perioperative Anxiety Scale, demographic data, cooperation with induction through the Induction Compliance Checklist, preoperative parental anxiety through the State-Trait Anxiety Inventory and Anxiety Visual Analog Scale, the postoperative delirium degree through the Pediatric Anesthesia Emergence Delirium Scale, the presence of behavioral changes through the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery, and the overall parental satisfaction.

RESULTS

A total of 125 participants were included; 61 (48.8%) of them were randomized to the Virtual Tour Group (VT+) and 64 (51.2%) to the Non-virtual Tour Group (VT-). Yale Preoperative Anxiety Scale results in VT+ vs. VT- were mean 27.26 vs. 32.57, and median 23.4 (CI 95% 23.4-23.4) vs. 23.4 (CI 95% 23.4-33.4), (p = .0086). In the VT+ group, satisfaction was higher for questions one (p = .0213), three (p = <.0001), and four (p = .0130). Throughout the study, we observed a significant reduction in perioperative anxiety in the VT+ group, facilitating anesthetic induction in perfect (p = .018) and moderate compliance (p = .0428). The other variables did not show statistically significant differences.

CONCLUSION

Our study confirms previous studies that found virtual tours for perioperative patients may reduce perioperative anxiety and improve satisfaction. We found no impact on longer-term outcomes.

Impact of Virtual Operating Room Tours on Relieving Perioperative Anxiety in Adult Patients: A Systematic Review

PURPOSE

To evaluate the effects of virtual operating room tours on perioperative anxiety in adult patients.

DESIGN

This study was a systematic review of randomized controlled trials (RCTs).

METHODS

PubMed, Cochrane Library, Embase, Web of Science, Proquest, Scopus, SinoMed, CNKI, and WanFang were systematically searched for English and Chinese RCTs published up to November 18, 2021, for studies on the effectiveness of virtual operating room tours in reducing perioperative anxiety in adult patients (>18 years of age). Primary and secondary outcomes were perioperative anxiety levels and understanding level of perioperative information and patient satisfaction, respectively. The data were synthesized using a qualitative method.

FINDINGS

Five studies were found eligible for inclusion; 3 studies showed a significant decrease in perioperative anxiety levels in patients of the virtual operating room tours group. Furthermore, the overall satisfaction, understanding of perioperative information, and preoperative preparedness were significantly enhanced respectively in 3 studies.

CONCLUSIONS

This study showed the effectiveness of virtual operating room tour on alleviating perioperative anxiety on adult patients. Furthermore, the satisfaction and understanding of perioperative information in intervention group improved owing to these tours. Future quantitative studies are needed to support these findings.