Virtual Reality Distraction during Endoscopic Urologic Surgery under Spinal Anesthesia: A Randomized Controlled Trial

Impact of virtual reality distraction during colonoscopy vs intravenous deep sedation: Results of a single-center randomized controlled trial

Background and study aims

Colonoscopy is associated with discomfort that requires intravenous sedation (IVS). The aim of this randomized controlled trial (RCT) was to explore the feasibility of virtual reality distraction (VRD) for colonoscopy using two primary endpoints: cecal intubation rate and the rate of rescue with IVS.

Patients and methods

Patients scheduled for elective colonoscopy with IVS were randomized in a 2:1 ratio in favor of VRD, with rescue IVS by propofol if needed. VRD involved use of a device providing a visual and auditive experience similar to clinical hypnosis.

Results

Ninety patients were included (VRD:60, IVS: 30). Cecal intubation rate was similar in both groups (92.8% for VRD vs 100% for IVS, P =0.3). The rate of rescue IVS in the VRD group was 63.6%. There was a decrease in median total dose of propofol per patient in the VRD group (1.15 mg/kg for VRD and 4.41 mg/kg for IVS, P <0.001) and in the subgroup of VRD patients who received IVS rescue (3.17 mg/kg for VRD and 4.41 mg/kg for IVS, P =0.003). The median level of pain was higher and the median level of comfort was lower in the VRD group (respectively 3 vs 0, P <0.001 and 7 vs 10, P <0.001).

Conclusions

This RCT provides preliminary data to better understand the feasibility of VRD for colonoscopy. We have not identified differences in procedure outcomes compared with conventional IVS, but nevertheless, higher pain and lower comfort scores were reported.

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.

The Effects of Virtual Reality Application on Pain Intensity, Anxiety Level and Patient Satisfaction in Patients Who Undergo Bronchoscopy: A Randomized Controlled Trial

BACKGROUND

Bronchoscopy is a medical procedure that allows imaging of the airways and lungs. With the help of a light and camera at its tip, the bronchoscope device can enter the airway and provide real-time visualization. Since most patients are conscious during the bronchoscopy procedure, they may experience pain and anxiety regarding possible complications and an uncertain outcome.

AIM

This study was conducted to determine the effects of virtual reality (VR) application on pain intensity, anxiety level, physiological symptoms of anxiety (vital signs) and patients' satisfaction level with the use of virtual reality while undergoing a bronchoscopy.

DESIGN

A parallel randomized controlled trial.

SETTING

Bronchoscopy unit of the chest diseases service of a 1053 bed university hospital in eastern Turkey.

SAMPLE AND METHODS

The study was conducted with a total of 70 patients, 35 in the intervention group and 35 in the control group. The researcher interviewed patients and approved those who met the research criteria and agreed to participate in the study. The researcher applied relaxation exercises to the patients in the intervention group using virtual reality glasses for 5 minutes before the procedure and 4-5 minutes during the procedure. No interventions were made for the patients in the control group. Data were collected using the Descriptive Information Form, Visual Analog Scale (VAS), Anxiety Assessment Scale (AAS), Physiological Symptoms of Anxiety Follow-up Form, and Virtual Reality Glasses Application Satisfaction Form.

RESULTS

When compared with the control group, the mean scores of VAS, AAS, heart rate, diastolic and systolic blood pressure, and respiratory rate of the intervention group were found to decrease significantly, while the O2 saturation value increased significantly (p < .05). It was found that 82.5% of the patients in the intervention group want to use virtual reality glasses if they have another intervention, and 70% recommend relaxation exercises with virtual reality glasses to patients who will undergo bronchoscopy.

CONCLUSION

Study results for this sample revealed that the use of VR decreased pain intensity scores, state anxiety levels, anxiety severity, diastolic blood pressure, systolic blood pressure, heart rate and respiratory rate, and increased O2 saturation in patients who underwent bronchoscopy. In line with these results, VR should be considered during bronchoscopy procedures.

Beyond Anesthesia: A Mini Review of Virtual Reality as an Adjunct in Urological Procedures

For selected endourological interventions, local anesthesia provides an alternative to general anesthesia and can avoid complications and reduce turnover times and health care costs. Virtual reality (VR) has emerged as a promising nonpharmacological adjunct with potential to improve local anesthesia tolerability. This mini-review examines the role of VR during urological procedures under local anesthesia. Ten studies were included from 559 screened articles. For more invasive procedures, VR use was often associated with significant pain and anxiety reductions, while other studies reported minimal effects. VR effectiveness varied according to the invasiveness of the procedure, patient anxiety, and VR content. While VR shows potential in urology, further research is needed to confirm its effectiveness across various interventions. PATIENT SUMMARY: We reviewed studies on the use of virtual reality to reduce pain and anxiety during urological procedures. The current evidence shows promise, but more studies in urology are needed in this emerging field.

Effect of Virtual Reality on Pain, Anxiety, and Vital Signs in Endoscopy

AIM

This study was conducted to evaluate the effect of relaxation exercise with VR (Virtual Reality) glasses on pain severity, anxiety level, and vital signs in patients undergoing endoscopy.

METHODS

This is a quasi-experimental study including a control group with a pretest/post-test applied. This study was conducted with a total of 100 patients, including 50 patients in the intervention and 50 patients in the control group. The data were collected by using Personal Information Form, Visual Analogue Scale (VAS), Visual Anxiety Scale, Vital Signs Form and Virtual Reality Glass Application Satisfaction Form.

RESULTS

In the inter group evaluation, the mean systolic and diastolic blood pressure, heart rate and respiratory rate of the patients in the experimental group after endoscopy were found to be lower than the control group (p < .05). When the effect size value (Cohen d) of this finding was examined, it was found that the application of virtual reality glasses had a large effect on systolic and diastolic blood pressure and a moderate effect on respiration and heart rate. It was found that the mean VAS score of the patients in the control group after the endoscopy procedure was significantly higher than their mean values before the procedure (p = .001). There was no statistically significant difference in the mean VAS scores, anxiety scores and O2 saturation values of the patients in the experimental and control groups after the endoscopy. The mean virtual reality glasses satisfaction value of the patients was found to be 6.98.

CONCLUSION

Relaxation exercise performed with virtual reality glasses has positive effects on mean systolic and diastolic blood pressure values, heart rate and respiratory rate in patients undergoing endoscopy. In line with these results, it is recommended that the use of virtual reality glasses during endoscopy should be widespread by nurses.

Virtual reality treatment could reduce anxiety for women undergoing cesarean section with spinal anesthesia: a randomized controlled trial

PURPOSE

Cesarean section may result in adverse psychosocial and behavioral outcomes because women put considerable emphasis on the process of birth. Virtual reality treatment has been shown by many studies to reduce anxiety and improve patient satisfaction. Therefore, we designed a randomized controlled trial to investigate whether the application of virtual reality technology during cesarean section can reduce maternal anxiety and improve satisfaction.

METHODS

We recruited 128 women undergoing elective cesarean delivery with proposed spinal anesthesia and randomly assigned them to either virtual reality or routine care. The virtual reality intervention was a virtual reality program tailored specifically for women undergoing cesarean section. Primary outcome was the change in anxiety score (change = preoperative-intraoperative score). Secondary outcomes included patient satisfaction score, requirement of intraoperative sedative and analgesic drugs, and respiratory rate.

RESULTS

The change in anxiety score in the virtual reality group was significantly higher than that in the routine care group (30 [20, 47.5] vs 10 [- 10, 23.8], respectively; P < 0.001, with Hodges-Lehmann median difference estimate of 20 (95% confidence interval CI, 15-30)). There were no significant differences between the two groups in patient satisfaction scores, the requirement of intraoperative sedative and analgesic drugs, and respiratory rate and side effects.

CONCLUSION

Virtual reality treatment could reduce the anxiety of women undergoing elective cesarean section, which is beneficial to the mother and baby. Trial registration This study was registered at the Chinese Clinical Trial Registry (ChiCTR2200061936) on July 11, 2022, and can be reached at https://www.chictr.org.cn/showprojEN.html?proj=173329.

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.

Can virtual reality enhance the patient experience during awake invasive procedures? A systematic review of randomized controlled trials

ABSTRACT

Procedural anxiety and pain negatively affect surgical outcomes and the patient experience during awake, invasive procedures (AIPs). This systematic review aims to evaluate the effect of using virtual reality (VR) to enhance the intraprocedural patient experience during AIPs. PRISMA, Cochrane, and SWiM Reporting Items guidelines were followed. PubMed, EMBASE, CENTRAL, and medRxiv databases were systematically searched for randomised controlled trials (RCTs) investigating the use of immersive VR headsets to enhance the patient experience in adults undergoing AIPs. Sixteen studies were included. The VR and control groups comprised 685 and 677 patients, respectively. Patients underwent endoscopic procedures in 9 studies ("endoscopic") and interventions that involved a skin incision in 7 studies ("incision"). Eleven (of 13) studies demonstrated a favourable effect on procedural anxiety with VR use compared with standard intraprocedural care (85% [95% CI: 46%-100%], P = 0.011). Ten (of 13) studies demonstrated a favourable effect on pain with VR use (77% [95% CI: 38%-100%], P = 0.046). Seven (of 9) studies demonstrated a favourable VR effect on patient satisfaction (78% (95% CI: 44%-100%), P = 0.070). The effect of VR on physiological markers of anxiety and pain and requirements for additional pro re nata (PRN) analgesia and sedation were not clear. No significant differences in patient experience were identified between the "incision" and "endoscopic" subgroups. This review demonstrates that VR can feasibly be used to enhance the patient experience during AIPs by attenuating subjective perceptions of procedural anxiety and pain. However, further RCTs are required to elucidate the effect of VR on more objective measures of the patient experience.

Virtual Reality for Pain Management During High-Resolution Manometry: A Randomized Clinical Trial

OBJECTIVE

High-resolution esophageal manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM is typically performed in the office with local anesthesia only, and many patients find it unpleasant and painful. The aim of this study was to examine the effects of the use of a virtual reality (VR) headset on pain and anxiety outcomes in patients with dysphagia undergoing HRM.

METHODS

Patients with dysphagia were prospectively recruited and randomized to undergo HRM with and without VR distraction. Data collected included the State-Trait Anxiety Inventory-6 (STAI-6), the Short-Form McGill Pain Questionnaire, heart rate, and galvanic skin response (GSR) tracings.

RESULTS

Forty subjects completed the study, including 20 subjects in the intervention arm and 20 in the control arm. There was evidence of a significant positive effect of VR on calmness (p = 0.0095) STAI-6 rating, as well as on physiologic measures of pain with significantly decreased GSR rise time (p = 0.0137) and average rate of change of conductance change (p = 0.0035).

CONCLUSION

The use of VR during HRM catheter insertion increased calmness compared to control. Change of skin conductance was also reduced in the VR group, suggesting decreased physiologic pain. This study supports the consideration of the use of VR as a distraction tool to improve patient comfort during HRM.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:1118-1126, 2024.

Virtual Reality Therapy as an Adjunct to Physiotherapy for Postoperative Pain Management: A Case Report of Laparoscopic Open Pyeloplasty for Hydronephrosis

Hydronephrosis occurs when the tubes connecting the kidneys and bladder become blocked. These tubes carry urine from the kidneys, where it is created, to the bladder, where it is stored until elimination. When one or both ureters get blocked, serious complications and symptoms might arise. These symptoms include urinary tract obstruction, urine backflow, kidney distension, increased intra-renal pressure, impaired kidney function, infection risk, urinary incontinence, which is the involuntary loss of urine, and discomfort in the side, abdomen, or groin. This case report describes the effective postoperative management of abdominal surgery with virtual reality therapy (VRT) combined with standard medical care as additional therapy and physical therapy for hydronephrosis in a 22-year-old male patient. After undergoing laparoscopic open pyeloplasty, the patient developed right-sided hydronephrosis due to ureteral stenosis. He had a ureteral stent inserted and received physical therapy, including pelvic floor muscle training, core strengthening, and diaphragmatic breathing exercises. After four weeks of physical therapy, the patient reported improvement in his symptoms, including reduced discomfort and increased urination. These findings imply that physical therapy, in addition to advanced treatment with the help of VRT for hydronephrosis following abdominal surgery, might be beneficial.

[The effects of hypnosis by virtual reality on tolerance to flexible bronchoscopy]

INTRODUCTION

Patients often perceive flexible bronchoscopy as an unpleasant procedure. The aim of this study was to investigate the effect of virtual reality (VR) hypnosis on tolerance to flexible bronchoscopy.

MATERIALS AND METHODS

We conducted a prospective, randomized, controlled, monocentric study comparing flexible bronchoscopy with VR-induced hypnosis to the usual procedure. Patient tolerance was evaluated using a visual analogue scale (VAS), the state-trait anxiety inventory (STAI) before and after the procedure and, finally, willingness to repeat the examination under the same conditions (WTR).

RESULTS

Among the 70 patients included, 34 were randomized to the VR hypnosis group and 36 to the control group. There was no difference between the 2 groups in terms of modification of the pre-/post-bronchoscopy VAS for anxiety, pain, cough, choking, nausea and overall discomfort, or modification of the STAI score and WTR. Subgroup analysis among patients who were more anxious before the procedure revealed a trend toward reduced anxiety in the VR hypnosis group.

CONCLUSION

This study did not observe any effect of VR hypnosis on the tolerance of patients during routine flexible bronchoscopy. However, VR hypnosis may be beneficial in patients with higher anxiety score before bronchoscopy, a hypothesis that needs to be confirmed by further studies with a larger number of subjects.

Augmented Reality for Perioperative Anxiety in Patients Undergoing Surgery: A Randomized Clinical Trial

Importance

Both augmented reality (AR) and virtual reality (VR) have had increasing applications in medicine, including medical training, psychology, physical medicine, rehabilitation, and surgical specialties, such as neurosurgery and orthopedic surgery. There are little data on AR's effect on patients' anxiety and experiences.

Objective

To determine whether the use of an AR walkthrough effects patient perioperative anxiety.

Design, Setting, and Participants

This randomized clinical trial was conducted at an outpatient surgery center in 2021 to 2022. All patients undergoing elective orthopedic surgery with the senior author were randomized to the treatment or control group. Analyses were conducted per protocol. Data analysis was performed in November 2022.

Intervention

AR experience explaining to patients what to expect on their day of surgery and walking them through the surgery space. The control group received the standard educational packet.

Main Outcomes and Measures

The main outcome was change in State-Trait Anxiety Inventory (STAI) from the screening survey to the preoperative survey.

Results

A total of 140 patients were eligible, and 45 patients either declined or were excluded. Therefore, 95 patients (63 [66.3%] male; mean [SD] age, 38 [16] years) were recruited for the study and included in the final analysis; 46 patients received the AR intervention, and 49 patients received standard instructions. The AR group experienced a decrease in anxiety from the screening to preoperative survey (mean score change, -2.4 [95% CI, -4.6 to -0.3]), while the standard care group experienced an increase (mean score change, 2.6 [95% CI, 0.2 to 4.9]; P = .01). All patients postoperatively experienced a mean decrease in anxiety score compared with both the screening survey (mean change: AR, -5.4 [95% CI, -7.9 to -2.9]; standard care, -6.9 [95% CI, -11.5 to -2.2]; P = .32) and preoperative survey (mean change: AR, -8.0 [95% CI, -10.3 to -5.7]; standard care, -4.2 [95% CI, -8.6 to 0.2]; P = .19). Of 42 patients in the AR group who completed the postoperative follow-up survey, 30 (71.4%) agreed or strongly agreed that they enjoyed the experience, 29 (69.0%) agreed or strongly agreed that they would recommend the experience, and 28 (66.7%) agreed or strongly agreed that they would use the experience again. No differences were observed in postoperative pain levels or narcotic use.

Conclusions and Relevance

In this randomized clinical trial, the use of AR decreased preoperative anxiety compared with traditional perioperative education and handouts, but there was no significant effect on postoperative anxiety, pain levels, or narcotic use. These findings suggest that AR may serve as an effective means of decreasing preoperative patient anxiety.

Trial Registration

ClinicalTrials.gov Identifier: NCT04727697.

Effects of Immersive Virtual Reality on Patient Anxiety During Surgery Under Regional Anesthesia: A Randomized Clinical Trial

Background

Surgery and anesthesia are associated with increased patient anxiety. Perioperative anxiety is a common problem in regional anesthesia procedures and has an extensive impact. Immersive virtual reality (IVR) is a potential non-pharmacological distraction method to reduce anxiety. Immersive virtual reality creates a virtual environment that allows patients to interact and immerse in the virtual world, reducing patient anxiety.

Objectives

This study aimed to examine the effect of IVR on the anxiety of patients undergoing regional anesthetic surgery.

Methods

A total of 30 participants referred to Dr. Kariadi General Hospital (Indonesia) from October 2021 to December 2021 were enrolled in this randomized, single-blind clinical trial. The patients were divided into virtual reality (VR) and control groups (n = 15 in each group). The control group received midazolam (0.02 mg/kg) as premedication. The VR group received an IVR intervention without premedication. The data of anxiety scores were assessed using the Spielberger State-Trait Anxiety Inventory 6 (STAI-6). This study also collected vital signs, side effects, and patient and surgeon satisfaction level data.

Results

The average anxiety level during surgery in the operating room decreased in both groups (P < 0.05); the VR group had a lower score (P = 0.04). A significant reduction in perioperative anxiety levels was observed in the VR group compared to the control group. The patient satisfaction level was also significantly higher in the VR group than in the control group (P = 0.024). Both groups had no significant difference in monitored vital signs, side effects, and surgeon satisfaction.

Conclusions

The IVR intervention could reduce anxiety in patients undergoing surgery under regional anesthesia and improve patient satisfaction.

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.

Effect of virtual reality on preoperative anxiety in patients undergoing septorhinoplasty

BACKGROUND

The aim of this study was to evaluate the effect of a virtual reality video on preoperative anxiety, hemodynamic parameters, and patient satisfaction in patients undergoing septorhinoplasty.

METHODS

This was a prospective, observational cohort trial. Forty patients between the ages of 18...65 who were scheduled for elective septorhinoplasty, with an American Society of Anesthesiologists (ASA) physical status I...II were included in the study. Patients experienced a 15-minute virtual reality (VR) video via a phone using a VR device. A three-dimensional, 360.. video depicted the beauty of nature and was accompanied by meditation music.

PATIENTS

.. oxygen saturation values, heart rate, and blood pressure were monitored and recorded. Using the State-Trait Anxiety Inventory scale, anxiety scores and hemodynamic parameters were compared before and after VR application.

RESULTS

Median anxiety scores decreased significantly from 40.5 to 34 (p.ß<.ß0.001). VR also had positive effects on hemodynamic parameters.

CONCLUSIONS

VR reduces preoperative anxiety and has positive effects on hemodynamic parameters in patients undergoing septorhinoplasty. We anticipate that VR will be increasingly used as a non-pharmacological preoperative approach in the future.

The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review

Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.

Effectiveness of Virtual Reality-Based Interventions for Managing Chronic Pain on Pain Reduction, Anxiety, Depression and Mood: A Systematic Review

(1) Background: Patients diagnosed with chronic pain suffer from long-term pain, which negatively affects their daily lives and mental health. Virtual reality (VR) technologies are considered a therapeutic tool to manage pain perception and mental health conditions. This systematic review aimed to appraise the efficacy of VR in improving pain intensity, anxiety, depression and mood among patients with chronic pain; (2) Methods: Five electronic databases were systematically searched using the terms representing VR and chronic pain. Quality assessment was conducted using Cochrane Collaboration’s tool and Newcastle-Ottawa scale; (3) Results: Seventeen peer-reviewed articles were included in this review. It was found that VR was able to reduce pain intensity in patients with phantom limb pain, chronic headache, chronic neck pain and chronic low-back pain. The effects of VR on the improvement of anxiety, depression and mood were not determined due to the inadequate amount of clinical evidence; (4) Conclusions: VR, especially immersive VR, improves pain outcomes and its effects may vary depending on the approach and study design. More research is still needed to investigate the clinical use of VR in patients with chronic pain.

Prospective randomized controlled trial to evaluate effectiveness of virtual reality to decrease anxiety in office-based flexible cystoscopy patients

PURPOSE

To evaluate the effectiveness of immersive VR distraction technology in alleviating anxiety and pain during flexible cystoscopy.

METHODS

We prospectively recruited 270 study participants who qualified for flexible cystoscopy and randomly assigned them to experimental and control groups. The experimental group consisted of 135 patients who employed a VR set during flexible cystoscopy, and the control group consisted of 135 patients who underwent the procedure without a VR set. Patient anxiety was determined quantitatively according to the State-Trait Anxiety Inventory. A visual analog scale for assessing pain intensity, satisfaction, and willingness to repeat the procedure was evaluated. In addition, difference in the hemodynamic parameter was also examined.

RESULTS

The study findings demonstrated that the use of a VR set during flexible cystoscopy significantly improved the anxiety level over that of the control group (p = 0.001). Furthermore, this intervention led to a significantly increased level of satisfaction and willingness to repeat the procedure and a decrease in hemodynamic variables, specifically, systolic pressure, diastolic pressure, and heart rate (p = 0.001 in each case). Nonetheless, there were no significant differences between the groups with respect to the basic characteristic data, pain intensity, or oxygen saturation.

CONCLUSIONS

Based on the present study, immersive VR can measurably decrease anxiety and increase satisfaction and willingness to repeat the procedure during flexible cystoscopy.

TRIAL REGISTRATION DATE

14 September 2019; number: TCTR20190914002.

Virtual reality distraction during upper gastrointestinal endoscopy: a randomized controlled trial

BACKGROUND AND AIM

Virtual reality (VR) is an established and effective tool in reducing autonomic and somatic pain. We aimed to examine the analgesic effects of VR distraction during esophagogastroduodenoscopy (EGD).

METHODS

We conducted a randomized controlled trial and enrolled patients who had indication for unsedated EGD with topical anesthesia. Patients were randomly assigned to use Oculus GO with three-dimensional specific software content (standalone VR headset), sham VR or without VR during EGD. The primary outcome was patient pain scores during EGD.

RESULTS

A total of 96 patients undergoing diagnostic EGD were randomized to receive VR (n = 32), sham VR (n = 32), and no VR defined as the control group (n = 32). Patients in all groups reported no statistically different pain during esophageal intubation. The mean pain score was 2.7 ± 2.4 in the VR group, 2.7 ± 2.5 in the sham VR and 2.3 ± 2.3 in the control group, (P value = 0.751). No significant difference was observed in heart rate and blood pressure, and the endoscopists reported higher overall satisfaction scores in VR (4.3 ± 0.5) compared with the control group (4 ± 0.8) but without significance (P value = 0.156).

CONCLUSION

Virtual reality-assisted anesthesia during EGD did not significantly reduce patient pain during esophageal intubation. There was no superiority in using VR distraction regarding patient's and endoscopist's satisfaction compared with standard EGD without VR Further studies are required to detect any true clinical advantage of VR distraction during EGD.

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.

Virtual reality interventions and the outcome measures of adult patients in acute care settings undergoing surgical procedures: An integrative review

AIMS

To evaluate the different types of virtual reality (VR) therapy received by adult patients undergoing surgical procedures in acute care settings and the outcome measures, as well as to highlight the acceptability and feasibility of VR approaches among patients and healthcare workers.

DESIGN

Whittemore and Knafl's integrative review method guided the analysis.

DATA SOURCES

Searches were conducted in ScienceDirect, ProQuest, Wiley Online Library, Medline, PsycINFO and PubMed and Google Scholar from 2000 to June 2021.

REVIEW METHODS

A systematic search on articles published in English was carried out with electronic databases and hand search references. Keywords searched included primary qualitative and quantitative studies that utilized VR therapy in surgical care settings.

RESULTS

Eighteen articles were reviewed, which reported the use of two main strategies: guided and interactive imagery therapy. The findings identified: (i) patient-clinical outcome measures including the use of analgesics, vital signs, functional capacity and length of hospital stay; and (ii) patient-reported experience measures including pain, anxiety and satisfaction level. Comfort, age, knowledge and attitude were key factors influencing the acceptability of VR among the patients, whereas cost-effectiveness and infection control were two main factors affecting the feasibility of use among the health care workers.

CONCLUSION

VR therapy demonstrated potential improvements in both the patient-clinical outcomes and patient-reported experiences of those undergoing surgical procedures. However, the findings were inconsistent, which required further research to explore and establish the effectiveness of using VR in the context of acute care settings.

IMPACT

VR distraction has been increasingly used as a non-pharmacological method in managing pain, easing anxiety and optimizing other associated outcomes in patients undergoing surgical procedures. It is essential to examine the effectiveness of VR therapy on the adult patients' outcomes in acute care settings with surgical procedures, as well as its acceptability and feasibility of use.

Nursing students' views of using virtual reality in healthcare: A qualitative study

AIMS AND OBJECTIVES

This study explored nursing students' views of using virtual reality in healthcare.

BACKGROUND

The popularity and use of virtual reality in healthcare delivery and education is on the rise. Yet, the views of future nurses regarding this technology remain underexplored.

DESIGN

This is a qualitative descriptive study guided by a naturalistic inquiry and reported using the Standards for Reporting Qualitative Research checklist.

METHODS

Nursing students (n = 26) were recruited using convenience and snowball sampling. They were first exposed to a virtual reality intervention aimed to enhance men's awareness of testicular diseases. This was attempted to familiarise participants with the technology and initiate conversations around its use in healthcare. Participants were then interviewed face-to-face, either individually or within focus groups. Data were analysed using thematic analysis.

RESULTS

Four themes were identified: (i) positive experiences of virtual reality; (ii) challenges to using virtual reality; (iii) settings where virtual reality can be implemented; and (iv) blue-sky and future applications of virtual reality. Participants described this technology as novel, enjoyable, immersive, memorable and inclusive. They questioned, however, the suitability of virtual reality for older adults, reported minor technical difficulties and stressed the importance of prior preparation in the use of the technology. Virtual reality was recommended for use in outpatient healthcare settings, schools and the community. Participants suggested using virtual reality in health promotion, disease prevention and management, and to promote nurses' empathy towards patients.

CONCLUSIONS

Findings highlight the potential role of virtual reality in assisting nurses in promoting health and managing disease. Future research is needed to establish the long-term effect of virtual reality interventions among more diverse participants.

RELEVANCE TO CLINICAL PRACTICE

Virtual reality can be implemented in outpatient, educational and community settings in order to promote health, prevent disease, enhance disease and self-management, and increase nurses' empathy towards patients.

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.

Effectiveness of virtual reality immersion on procedure-related pain and anxiety in outpatient pain clinic: an exploratory randomized controlled trial

Background

The study investigated virtual reality (VR) immersion in alleviating procedure-related pain in patients with chronic pain undergoing fluoroscopy-guided minimally-invasive intervention in a prone position at an outpatient clinic.

Methods

In this prospective randomized controlled study, 38 patients undergoing lumbar sympathetic ganglion block were randomized into either the VR or the control group. In the VR group, procedure-related pain was controlled via infiltration of local anesthetics while watching a 30-minute VR hypnotic program. In the control group, the skin infiltration alone was used, with the VR device switched off. The primary endpoint was an 11-point score on the numerical rating scale, indicating procedure-related pain. Patients’ satisfaction with pain control, anxiety levels, the need for additional local anesthetics during the procedure, hemodynamic stability, and any adverse events were assessed.

Results

Procedure-related pain was significantly lower in the VR group (3.7 ± 1.4) than in the control group (5.5 ± 1.7; P = 0.002). Post-procedural anxiety was lower in the VR group than in the control group (P = 0.025), with a significant reduction from pre-procedural anxiety (P < 0.001). Although patients’ satisfaction did not differ significantly (P = 0.158) between the groups, a higher number of patients required additional local anesthetics in the control group (n = 13) than in the VR group (n = 4; P = 0.001). No severe adverse events occurred in either group during the study.

Conclusions

VR immersion can be safely used as a novel adjunct to reduce procedural pain and anxiety during fluoroscopic pain intervention.

The use of virtual reality in reducing anxiety during cast removal: a randomized controlled trial

PURPOSE

While virtual reality (VR) has been shown to be an effective distractor in children across a range of procedures, no studies have looked at its use within paediatric orthopaedics. The purpose of this study was to look at the use of VR in reducing anxiety levels in children during cast removal. In addition, the study aimed to find ways to enhance the efficiency of future VR trials in paediatrics.

METHODS

A non-blinded randomized control trial took place in children aged four to 18 years. Intraprocedural anxiety was measured using the Children's Emotional Manifestation Scale (CEMS), while pre- and post-procedural anxiety was measured using the Short State Anxiety Inventory Scale. Additional data was collected on trait anxiety, nausea levels, desire for future VR use and areas of improvement for future VR studies.

RESULTS

A total of 90 subjects were included in the study (control n = 45, intervention n = 45) with a mean age of 10.25 years (sd 3.35). Post-procedural anxiety and intraprocedural anxiety were 18% (p = 0.03) and 24% (p = 0.01) lower in the VR group, respectively, with the CEMS facial component showing a 31% (p < 0.001) reduction in the VR group. In all, 99% (n = 89) of subjects experienced no nausea, with one patient experiencing mild nausea that may have been present prior to VR use. Finally, 90% (n = 81) of subjects said they would like to use VR again, 1% (n = 1) said 'no' and 9% (n = 8) said 'maybe'.

CONCLUSION

VR appears to be an effective distraction technique in reducing anxiety levels in children during cast removal.

Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines-part 2: management and recommendations

BACKGROUND

In Europe, healthcare systems and education, as well as the clinical care and health outcomes of patients, varies across countries. Likewise, the management of acute events for patients also differs, dependent on the emergency care setting, e.g. pre-hospital or emergency department. There are various barriers to adequate pain management and factors common to both settings including lack of knowledge and training, reluctance to give opioids, and concerns about drug-seeking behaviour or abuse. There is no single current standard of care for the treatment of pain in an emergency, with management based on severity of pain, injury and local protocols. Changing practices, attitudes and behaviour can be difficult, and improvements and interventions should be developed with barriers to pain management and the needs of the individual emergency setting in mind.

METHODS

With these principles at the forefront, The European Society for Emergency Medicine (EUSEM) launched a programme-the European Pain Initiative (EPI)-with the aim of providing information, advice, and guidance on acute pain management in emergency settings.

RESULTS AND CONCLUSIONS

This article provides treatment recommendations from recently developed guidelines, based on a review of the literature, current practice across Europe and the clinical expertise of the EPI advisors. The recommendations have been developed, evaluated, and refined for both adults and children (aged ≥ 1 year, ≤ 15 years), with the assumption of timely pain assessment and reassessment and the possibility to implement analgesia. To provide flexibility for use across Europe, options are provided for selection of appropriate pharmacological treatment.

Use of Virtual Reality to Reduce Anxiety and Pain of Adults Undergoing Outpatient Procedures

(1) Background: Research has demonstrated that virtual reality (VR) has reduced pain and anxiety for patients undergoing health procedures. The aim of this quality improvement project was to implement and evaluate immersive VR as a non-pharmacological intervention to reduce pain and anxiety in those adults undergoing outpatient procedures under monitored anesthesia care. (2) Methods: This quality improvement project incorporated the Plan-Do-Study-Act (PDSA) model and employed a pre/post-implementation evaluation. Seven patients used VR during outpatient surgeries. Pain and anxiety scores were evaluated. (3) Results: Patients using VR exhibited lower pain and anxiety scores post-procedure compared to pre-procedure. Both patients and providers indicated high satisfaction with the VR experience. (4) Conclusions: This quality improvement project demonstrated the successful translation of research into practice. VR is a novel intervention that can reduce both pain and anxiety to improve the patient’s perioperative experience.

Regional anesthesia combined with virtual reality hypnosis for extended orthopedic surgery: two case reports

Background : Virtual reality hypnosis is a combination of visual immersion in a virtual reality environment and clinical hypnosis. It can be used in addition to conventional techniques, for sedation and pain management during wound care. Patients undergoing painful and long-lasting procedures under regional anesthesia could also benefit, from this technique alleviating the need for sedative-hypnotic medication. Case presentation : Two patients with relative contra- indications for general anesthesia underwent lengthy orthopedic surgery of the upper limbs under regional anesthesia with additional virtual reality hypnosis. Written informed consent was obtained from both patients before surgery. A 69-year-old man, with a previous medical history of severe symptomatic aortic valve stenosis (ѳ 0.69cm2, max/mean gradient of 91/58mmHg) sustained a proximal humerus fracture-dislocation and was scheduled to undergo shoulder hemi-arthroplasty. Anesthesia was provided with ultrasound-guided continuous interscalene block at the C5-C6 level (11mL levobupivacaine 0.5%) combined with a single-shot superficial cervical plexus block (6mL levobupivacaine 0.5%). The second case was a 56-year-old man suffering from rheumatoid arthritis with severe restrictive lung function due to interstitial lung disease and bilateral bronchiectasis. He received a unilateral elbow prosthesis. Continuous infra-clavicular brachial plexus block, per- formed under ultrasound guidance was provided (20 mL mepivacaine 1.5%). Both patients required prolonged immobilization on the operating table. We used virtual reality hypnosis to induce sedation and improve comfort without using medication. This was provided by headphones and head-mounted goggles, showing computer generated images of underwater scenes (Aqua module, Oncomfort ™). Both surgeries were uneventful during which time cardiorespiratory stability was maintained. Patients were comfortable during and satisfied after surgery. No sedative drugs were given before nor during the procedures. Conclusion : Non-pharmacological sedation can be achieved with virtual reality hypnosis. When com- bined with regional anesthesia, this technique provides satisfactory sedation when pharmacological methods may be hazardous.

Virtual Reality as Distraction Analgesia for Office-Based Procedures: A Randomized Crossover-Controlled Trial

OBJECTIVE

The purpose of this study was to explore the use of immersive and interactive virtual reality (VR) for analgesia, anxiety reduction, and overall satisfaction in patients undergoing outpatient postoperative debridements.

STUDY DESIGN

Randomized crossover-controlled trial.

SETTING

Academic outpatient clinic.

SUBJECTS AND METHODS

Adult patients who had functional endoscopic sinus surgery and skull base surgery and were undergoing office-based postoperative nasal endoscopy and debridement were recruited and followed for 2 consecutive office visits. Participants were randomized to receive either the control or experimental analgesia for the first postoperative visit (PO1) and crossed over into the opposite treatment arm during the second postoperative visit (PO2). Outcomes included procedural pain, anxiety and satisfaction scores, procedural time, and reflexive head movements per minute (RHM).

RESULTS

Eighty-two participants were recruited. At PO1, 39 received standard analgesia, and 43 received an immersive VR experience. At PO1, the VR group experienced significantly less anxiety (P = .043) and fewer RHM (P = .00016) than the control group. At PO2, the VR group experienced significantly fewer RHM (P = .0002). At PO2, patients who received the experimental treatment after initially receiving the control treatment had significantly decreased pain, anxiety, and RHM. This effect was not seen in the second group. Overall, 69.51% of patients felt that the VR treatment was better; 19.51% thought that it was the same; and 9.76% found it to be worse.

CONCLUSION

VR technology holds promise as a nonpharmacologic analgesic and anxiolytic intervention for otolaryngology office-based procedures. Further study of VR use in other procedures is warranted.

LEVEL OF EVIDENCE

1, randomized controlled trial.

Integrative Medicine in Interventional Oncology: A Virtuous Alliance

This review aimed to identify the potential role of integrative medicine in interventional oncology. The music therapy; stress management techniques; guided imagery, including virtual reality; clinical hypnosis; and digital sedation may all be efficient on anxiety and pain during procedures performed in interventional oncology. Beyond pharmacological sedation, the implementation of integrative medicine to interventional oncology may, therefore, improve the support and care of cancer patients, which may further create a virtuous alliance.

Virtual Reality for PEripheral Regional Anesthesia (VR-PERLA Study)

When used as an add-on to regional anesthesia, virtual reality (VR) has been reported to provide anxiety-reducing benefits and sedation-sparing effects. However, its impact on patient satisfaction is still a matter of controversy. We investigated the feasibility and benefits of implementing intraoperative VR distraction in a French University Hospital (Hôpital Saint-Antoine, AP-HP). This monocentric observational before–after study included 100 patients who underwent ambulatory upper limb surgery under peripheral nerve block in January 2019, 50 before and 50 after implementation of an intraoperative VR distraction protocol. Primary outcome was patient self-rated satisfaction score evaluated right after surgery. Secondary outcomes included 2-month patient-reported satisfaction score, perioperative self-rated anxiety and intraoperative hemodynamic changes. Compared to former standard care, VR distraction was associated with significantly higher postoperative satisfaction scores (10 [IQR 9; 10] vs. 9 [8; 10], p < 0.001) still reported two months after surgery (10 [10;10] vs. 10 [8.5;10], p = 0.06). Patient median intraoperative anxiety score was lower in the VR group, compared to Standard Care group (0 [0; 2] vs. 3 [0.25; 7], p < 0.001), and occurrence of intraoperative hemodynamic changes was also lessened in the VR group (2% vs. 16%, 0R = 0.11[95% CI 0.002–0.87], p = 0.031). The present findings suggest that VR distraction program in the operating room could effectively improve patient satisfaction with anxiety-reduction and hemodynamic benefits.

Sedation and analgesia in interventional radiology: Where do we stand, where are we heading and why does it matter?

The aims of this review were to describe the rationale and the techniques of sedation in interventional radiology, and to compile the safety and efficacy results available so far in the literature. A systematic MEDLINE/PubMed literature search was performed. Preliminary results from several studies demonstrated the feasibility, the efficacy and the safety of using sedative techniques in interventional radiology. Beyond pharmacological sedation and clinical hypnosis, digital sedation could reduce the anxiety and pain associated with interventional radiology procedures.

Is virtual reality useful for pain management in patients who undergo medical procedures?

Pain management is a complex medical issue, and many efforts have been done to develop new non-pharmacological therapies. Virtual reality is a technology apparatus that make an interaction between human and virtual environment through an hardware (usually a headset) linked to a computer or a mobile, by using a software. Additionally, this virtual setting can be adapted to any type of scenario. Thus, it is plausible that the software used should be personalized depending on patient’s experiences and expectations. The use of virtual reality as a medical tool for pain relief or decrease analgesics use by promoting a cognitive distraction is a low cost and promising instrument for pain management in patients who undergo medical procedures.