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

Abstract

Background: Perioperative pediatric anxiety is common and can have a negative psychological impact on children undergoing surgery and anesthesia. Studies have shown an incidence of anxiety at induction of up to 50%. Audiovisual distraction, including virtual reality (VR), is a noninvasive, nonpharmacological modality that may reduce perioperative anxiety. The goal of this study was to determine whether immersive audiovisual distraction with a VR headset during induction of general anesthesia (GA) in pediatric patients reduced preoperative anxiety.

Methods: In this randomized-controlled, parallel-group study, 71 children 5-12 years of age scheduled for elective surgery with GA were randomly allocated to a VR group or a non-VR (No VR) control group. VR group patients underwent audiovisual distraction with a VR headset during induction in the operating room, whereas the control group received no audiovisual distraction. The primary outcome was the Modified Yale Preoperative Anxiety Scale (mYPAS), which was measured at 3 time points to assess patient anxiety: in the preoperative holding area before randomization, on entering the operating room, and during induction of GA. The primary outcome was analyzed using univariate analysis and a linear mixed-effects model. Secondary outcomes included postinduction parental anxiety measured by the State-Trait Anxiety Inventory, pediatric induction compliance, and parental satisfaction.

Results: Average patient age was 8.0 ± 2.3 years (mean ± standard deviation [SD]), and 51.4% of patients were female. Baseline variables were not substantially different between the VR group (33 patients) and the No VR group (37 patients). No patients received preoperative anxiolytic medication. Baseline mYPAS scores were not different between the groups, with scores of 28.3 (23.3-28.3) (median [interquartile range {IQR}]) in both. The change in mYPAS scores from baseline to time of induction was significantly lower in the VR group versus control group (0.0 [0.0-5.0] vs 13.3 [5.0-26.7]; P < .0001). In the mixed-effects model, the VR group had an estimated 6.0-point lower mYPAS score (95% confidence interval [CI], 0.7-11.3; P = .03) at room entry than the No VR group, and 14.5-point lower score (95% CI, 9.3-19.8; P < .0001) at induction versus control. Randomization to VR did not alter parental anxiety (0 [-2 to 2]), pediatric induction compliance (0 [0-0]), or parental satisfaction (-3 [-8 to 2]) (difference in medians [95% CI]).

Conclusions: This study demonstrates a reduction in pediatric preoperative anxiety with the use of VR. Preoperative VR may be an effective noninvasive modality for anxiolysis during induction of anesthesia in children.

Trial registration: ClinicalTrials.gov NCT03583450.

Conflict of interest statement

Conflicts of Interest: See Disclosures at the end of the article.

Copyright © 2020 International Anesthesia Research Society.

Figures

Figure 1:

Consolidated Standards of Reporting Trials (CONSORT) flow diagram of participants.

Figure 2:

Box plot of raw mYPAS scores in the virtual reality (VR) and No VR groups. T0 = baseline in preoperative holding area (gray), T1 = entry into the operating room (yellow), T2 = during induction of general anesthesia (green). The mixed-effects model controlled for the baseline mYPAS score and demonstrated significant interaction between time and group assignment (p=0.003).

Figure 3:

Box plot of mYPAS individual score differences in the VR and No VR groups. T1-T0 (yellow) = difference between T1 (entry into the operating room) and T0 (baseline in preoperative holding area). T2-T0 (green) = difference between T2 (during induction of general anesthesia) and T0 (baseline in preoperative holding area). Both mYPAS score differences were significantly different between the VR and No VR groups (p<0.0001).