Virtual reality-assisted distraction during transcatheter aortic valve implantation under local anaesthesia: A randomised study

Anxiety during transcatheter aortic valve replacement under local anesthesia - the ART-VR trial

BACKGROUND

The use of local anesthesia during transcatheter aortic valve replacement (TAVR) could result in patient discomfort. Application of immersive virtual reality (VR) during TAVR might distract the patient and enhance the overall experience.

OBJECTIVE

To evaluate the effect of an immersive VR environment on periprocedural anxiety and patient discomfort, compared to standard of care in patients undergoing transfemoral (TF) TAVR under local anesthesia.

METHODS

In this single-center, randomized controlled pilot study, patients were randomized to either VR immersion during TAVR or standard of care. The intervention was a VR headset to create 3D experiences during percutaneous transfemoral TAVR. The main outcome was patient-reported procedural anxiety assessed directly after the procedure on a visual analog scale (VAS). Secondary outcomes were procedural satisfaction, pain, and change in anxiety. Personality scores were obtained at baseline to explore associations between personality types and relevant outcomes.

RESULTS

A total of 75 patients (VR = 37, control = 38) were included between September 2021 and January 2023. The median age was 79 (25th-75th: 75-84) years and 32 patients (43 %) were female. Overall procedural anxiety VAS was 1.0 (0.0-3.0) and satisfaction was 9.0 (8.0-10.0). There was no difference in procedural anxiety between VR and control (VAS: 1.0 [25th-75th: 0.0-3.0] versus 1.0 [25th-75th: 0.0-3.0], p = 0.59). Procedural satisfaction, pain perception and change in anxiety were not affected by VR use.

CONCLUSION

Patients undergoing TF-TAVR under local anesthesia experienced mild procedural anxiety and high satisfaction levels. Procedural VR use did not affect procedural anxiety or pain perception.

Do Extended Reality Interventions Benefit Patients Undergoing Elective Cardiac Surgical and Interventional Procedures? A Systematic Review and Meta-analysis

BACKGROUND

Extended reality (XR) interventions have the potential to benefit patients undergoing elective cardiac surgical and interventional procedures. However, there are no systematic reviews with meta-analyses to guide clinical care.

AIM

To critically evaluate the evidence on the effectiveness of XR interventions on patient anxiety and pain and other associated outcomes.

DESIGN

Systematic review and meta-analysis following the PRISMA 2020 statement.

DATA SOURCES

A systematic search of five databases (CENTRAL, CINAHL, MEDLINE, PsycInfo, Scopus) from inception to July 2023.

METHODS

Screening and data extraction was conducted independently by multiple reviewers. Stata (Version 17) was used to conduct meta-analyses for patient anxiety and pain. Secondary patient outcomes were summarised in a synthesis. The Cochrane Risk of Bias (Version 2) tool was applied to trials and the NHLBI Study Quality Assessment tools to all other study designs.

RESULTS

Of the 3372 records identified, 22 were included, 10 of which were eligible for inclusion in the meta-analyses. Fifty-seven percent of randomised trials were rated as high risk of bias. Virtual reality (VR) was the only XR technology evaluated. VR significantly reduced pre-procedural anxiety (standardised mean difference: -1.29; 95% confidence interval - 1.96, -0.62, p < 0.001), and peri-procedural anxiety (standardised mean difference: -0.50; 95% confidence interval - 0.83, -0.18, p < 0.003) but did not reduce pain levels, compared with usual care. VR increased pre-procedural knowledge and postsurgical physical and pulmonary function. VR interventions may also improve emotional wellbeing, care delivery and physiological outcomes, but evidence was inconsistent.

CONCLUSIONS

XR potentially benefits cardiac patients undergoing elective invasive procedures and surgery by reducing pre- and peri-procedural anxiety and increasing procedural knowledge and physical function.

RELEVANCE TO CLINICAL PRACTICE

Cardiac nurses' role can be supported by VR interventions to improve the patient experience and several aspects of patient care.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable as this is a systematic review.

Current Clinical and Educational Uses of Immersive Reality in Anesthesia: Narrative Review

BACKGROUND

The concept of immersive reality (IR), an umbrella term that encompasses virtual reality, augmented reality, and mixed reality, has been established within the health care realm as a potentially valuable tool with numerous applications in both medical education and patient care.

OBJECTIVE

This review aimed to introduce anesthesiologists to the emerging and rapidly evolving literature on IR, its use in anesthesia education, and its transferability into the clinical context.

METHODS

A review of the relevant literature was conducted using the PubMed database from inception to July 5, 2023. Additional references were identified from the reference lists of selected papers.

RESULTS

A total of 51 papers related to the use of IR in anesthesia medical education (including both technical and nontechnical skills) and 63 papers related to applications in clinical practice (eg, preprocedure planning, patient education, and pain management) were included. We present evidence supporting the use of IR in the training and clinical practice of modern anesthesiologists.

CONCLUSIONS

IR is useful for a variety of applications in anesthesia medical education and has potential advantages over existing simulation approaches. Similarly, IR has demonstrated potential improvements in patient care across several clinical contexts relevant to practicing anesthesiologists. However, many applications remain in the early stages of development, and robust trials are urgently needed to confirm clinical or educational effectiveness and to assess mechanisms, educational validity, and cost-effectiveness.

Artificial Intelligence-Assisted Virtual Reality for Reducing Anxiety in Pediatric Endoscopy

Background/Objectives: This study aimed to evaluate the effects of artificial intelligence (AI)-assisted virtual reality (VR) applications on preoperative anxiety levels and vital signs in children undergoing endoscopy. Methods: A randomized controlled trial design was employed, including a total of 80 children aged 8-17 years (40 in the intervention group and 40 in the control group). Children in the intervention group were exposed to VR applications featuring space and underwater themes, while the control group received standard procedures. Anxiety levels were assessed using the "State-Trait Anxiety Inventory for Children (STAIC)", and vital signs were evaluated through measurements of systolic and diastolic blood pressure, heart rate, temperature, and SpO2. Results: VR applications significantly reduced anxiety scores in the intervention group (36.3 ± 1.9), while no significant changes were observed in the control group (45.4 ± 2.74) (p < 0.001). Regarding vital signs, more favorable outcomes were observed in the intervention group. Systolic blood pressure was measured as 89 ± 6.7 mmHg in the intervention group and 96.5 ± 10.5 mmHg in the control group (p < 0.001). Diastolic blood pressure was 60.8 ± 4.7 mmHg in the intervention group and 63.8 ± 6 mmHg in the control group (p < 0.05). Heart rate was recorded as 88.7 ± 10.1 bpm in the intervention group and 94.5 ± 14.8 bpm in the control group (p < 0.05). SpO2 levels were 98 ± 1 in the intervention group and 96.2 ± 1.3 in the control group (p < 0.001). Conclusions: AI-assisted VR applications emerge as an effective non-pharmacological method for reducing preoperative anxiety and promoting physiological stability in children. This approach holds the potential to enhance pediatric experiences during invasive procedures such as endoscopy.

Multicenter, randomized, controlled comparative-effectiveness study comparing virtual reality to sedation and standard local anesthetic for pain and anxiety during epidural steroid injections

Background

The use of sedation during interventional procedures has continued to rise resulting in increased costs, complications and reduced validity during diagnostic injections, prompting a search for alternatives. Virtual reality (VR) has been shown to reduce pain and anxiety during painful procedures, but no studies have compared it to a control and active comparator for a pain-alleviating procedure. The main objective of this study was to determine whether VR reduces procedure-related pain and other outcomes for epidural steroid injections (ESI).

Methods

A randomized controlled trial was conducted in 146 patients undergoing an ESI at 6 hospitals in Thailand and the United States. Patients were allocated to receive immersive VR with local anesthetic, sedation with midazolam and fentanyl plus local anesthetic, or local anesthetic alone. The primary outcome was procedure-related pain recorded on a 0-10 scale. Other immediate-term outcome measures were pain from a standardized subcutaneous skin wheal, procedure-related anxiety, ability to communicate, satisfaction, and time to discharge. Intermediate-term outcome measures at 4 weeks included back and leg pain scores, function, and success defined as a ≥2-point decrease in average leg pain coupled with a score ≥5/7 on a Patient Global Impression of Change scale.

Findings

Procedure-related pain scores with both VR (mean 3.7 (SD 2.5)) and sedation (mean 3.2 (SD 3.0)) were lower compared to control (mean 5.2 (SD 3.1); mean differences -1.5 (-2.7, -0.4) and -2.1 (-3.3, -0.9), respectively), but VR and sedation scores did not significantly differ (mean difference 0.5 (-0.6, 1.7)). Among secondary outcomes, communication was decreased in the sedation group (mean 3.7 (SD 0.9)) compared to the VR group (mean 4.1 (SD 0.5); mean difference 0.4 (0.1, 0.6)), but neither VR nor sedation was different than control. The trends favoring sedation and VR over control for procedure-related anxiety and satisfaction were not statistically significant. Post-procedural recovery time was longer for the sedation group compared to both VR and control groups. There were no meaningful intermediate-term differences between groups except that medication reduction was lowest in the control group.

Interpretation

VR provides comparable benefit to sedation for procedure-related pain, anxiety and satisfaction, but with fewer side effects, superior communication and a shorter recovery period.

Funding

Funded in part by grants from MIRROR, Uniformed Services University of the Health Sciences, U.S. Dept. of Defense, grant # HU00011920011. Equipment was provided by Harvard MedTech, Las Vegas, NV.

Effectiveness of virtual reality on pain and anxiety in patients undergoing cardiac procedures: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Cardiac procedures often induce pain and anxiety in patients, adversely impacting recovery. Pharmachological approaches have limitations, prompting exploration of innovative digital solutions like virtual reality (VR). Although early evidence suggests a potential favourable benefit with VR, it remains unclear whether the implementation of this technology can improve pain and anxiety. We aimed to assess by a systematic review and meta-analysis the effectiveness of VR in alleviating anxiety and pain on patients undergoing cardiac procedures.

METHODS

Our study adhered to the PRISMA method and was registered in PROSPERO under the code CRD42024504563. The search was carried out in the PubMed, Web of Science, Scopus, and the Cochrane Library databases in January 2024. Four randomized controlled trials were included (a total of 382 patients). Risk of bias was employed to assess the quality of individual studies, and a random-effects model was utilized to examine the overall effect.

RESULTS

The results showed that VR, when compared to the standard of care, had a statistically significant impact on anxiety (SMD = -0.51, 95 % CI: -0.86 to -0.16, p = 0.004), with a heterogeneity I2 = 57 %. VR did not show a significant difference in terms of pain when compared to standard care (SMD= -0.34, 95 % CI: -0.75 to -0.07, p = 0.10). The included trials exhibited small sample sizes, substantial heterogeneity, and variations in VR technology types, lengths, and frequencies.

CONCLUSIONS

VR effectively lowers anxiety levels in patients undergoing cardiac procedures, however, did not show a statistically significant difference on pain.

Pain and anxiety management with virtual reality for office hysteroscopy: systemic review and meta-analysis

PURPOSE

Office hysteroscopy (OH) is a commonly performed procedure, although it might be associated with some degree of pain and anxiety. Our aim was to determine the effects of virtual reality on pain and anxiety levels felt by patients undergoing OH.

METHODS

MEDLINE, Embase, Google Scholar, Cochrane Library, clinicaltrials.gov, ProQuest, Grey literature, and manual searching of references within studies found in the initial search were systematically searched using the terms 'Virtual Reality' and 'Hysteroscopy' without time or language limitations. The review considered all studies assessing the impact of virtual reality (VR) over OH outcomes, and prospective randomized trials were included in the meta-analysis. Retrospective and case - control studies were excluded from the meta-analysis.

RESULTS

We identified 17 studies, of which four randomized controlled studies were included in the meta-analysis (327 participants, 168 in the VR group and 159 in the control group). On a 0-10 scale, pain sensation and maximal pain sensation during the operation were not statistically different between study and control groups (relative risk (RR) =  -0.64, 95% C.I (-1.57)0.29) and (RR = -0.93, 95% C.I (-3.33) - 1.47), respectively. Anxiety measurement was statistically lower in the study group (RR = -1.73, 95% C.I (-2.79) - ( -0.67)).

CONCLUSIONS

The available data suggest that VR techniques do not decrease the pain sensation during OH however, they do contribute to a reduction in the anxiety levels experienced by patients. PROSPERO registration number CRD42023432819.

Virtual Reality for the Management of Pain and Anxiety in Patients Undergoing Implantation of Pacemaker or Implantable Cardioverter Defibrillator: A Randomized Study

BACKGROUND

The Virtual Reality Headset (VRH) is a device aiming at improving patient's comfort by reducing pain and anxiety during medical interventions. Its interest during cardiac implantable electronic devices (CIED) implant procedures has not been studied.

METHODS

We randomized consecutive patients admitted for pacemaker or Implantable Cardioverter Defibrillator (ICD) at our center to either standard analgesia care (STD-Group), or to VRH (VRH-Group). Patients in the STD-Group received intra-venous paracetamol (1 g) 60 min before the procedure, and local anesthesia was performed with lidocaine. For patients of the VRH-Group, VRH was used on top of standard care. We monitored patients' pain and anxiety using numeric rating scales (from 0 to 10) at the time of sub-cutaneous pocket creation, and during deep axillary vein puncture. Patient comfort during the procedure was assessed using a detailed questionnaire. Morphine consumption was also assessed.

RESULTS

We randomized 61 patients to STD-Group (n = 31) or VRH-Group (n = 30). Pain and anxiety were lower in the VRH-Group during deep venous puncture (3.0 ± 2.0 vs. 4.8 ± 2.2, p = 0.002 and 2.4 ± 2.2 vs. 4.1 ± 2.4, p = 0.006) but not during pocket creation (p = 0.58 and p = 0.5). Morphine consumption was lower in the VRH-Group (1.6 ± 0.7 vs. 2.1 ± 1.1 mg; p = 0.041). Patients' overall comfort during procedure was similar in both groups.

CONCLUSION

VRH use improved pain and anxiety control during deep venous puncture compared to standard analgesia care, and allowed morphine consumption reduction. However, pain and anxiety were similar at the time of sub-cutaneous pocket creation.

Using Immersive Virtual Reality Distraction to Reduce Fear and Anxiety before Surgery

Presurgical anxiety is very common and is often treated with sedatives. Minimizing or avoiding sedation reduces the risk of sedation-related adverse events. Reducing sedation can increase early cognitive recovery and reduce time to discharge after surgery. The current case study is the first to explore the use of interactive eye-tracked VR as a nonpharmacologic anxiolytic customized for physically immobilized presurgery patients. Method: A 44-year-old female patient presenting for gallbladder surgery participated. Using a within-subject repeated measures design (treatment order randomized), the participant received no VR during one portion of her preoperative wait and interactive eye-tracked virtual reality during an equivalent portion of time in the presurgery room. After each condition (no VR vs. VR), the participant provided subjective 0-10 ratings and state-trait short form Y anxiety measures of the amount of anxiety and fear she experienced during that condition. Results: As predicted, compared to treatment as usual (no VR), the patient reported having 67% lower presurgical anxiety during VR. She also experienced "strong fear" (8 out of 10) during no VR vs. "no fear" (0 out of 10) during VR. She reported a strong sense of presence during VR and zero nausea. She liked VR, she had fun during VR, and she recommended VR to future patients during pre-op. Interactive VR distraction with eye tracking was an effective nonpharmacologic technique for reducing anticipatory fear and anxiety prior to surgery. The results add to existing evidence that supports the use of VR in perioperative settings. VR technology has recently become affordable and more user friendly, increasing the potential for widespread dissemination into medical practice. Although case studies are scientifically inconclusive by nature, they help identify new directions for future larger, carefully controlled studies. VR sedation is a promising non-drug fear and anxiety management technique meriting further investigation.