JMIR Publications

ABSTRACT

Background:

Children commonly experience high levels of anxiety at induction of general anesthesia. This distress is associated with postoperative maladaptive behaviors. Virtual reality (VR) is an innovative tool for reducing anxiety and pain during various medical procedures. Previous randomized controlled trials have demonstrated its effectiveness in reducing children’s anxiety in the preoperative waiting room and even during induction.

Objective:

The primary aim of this study was to examine the feasibility of VR distraction throughout the perioperative period, from the waiting room until induction of general anesthesia. Secondary aims were to assess its clinical utility, tolerability, and initial clinical efficacy.

Methods:

A mixed-methods, concurrent triangulation, VR2 feasibility trial was piloted at the [location removed for peer review]. Participants played an interactive VR game (DREAM by Paperplane Therapeutics) throughout the perioperative period. Feasibility was examined with the duration of the VR intervention. Clinical utility was assessed using a perception questionnaire. Tolerability was evaluated by the child simulator sickness questionnaire (CSSQ). Initial clinical efficacy was assessed by the FACES Pain Scale-Revised, FACES Anxiety Scale, Graphic Rating Scale for multidimensional pain, the Induction Compliance Checklist, and the pediatric anesthesia emergence delirium scale. Quantitative data was supported with fieldnotes and semi-structured interviews with patients and parents. Quantitative and qualitative themes were compared via the triangulation protocol to produce final themes.

Results:

Thirty-nine patients (mean age = 11.9; SD = 2.8) undergoing elective surgery under general anesthesia participated in the study. The healthcare team, patients, and parents were receptive and willing to adapt to VR. Nineteen patients (48.7%) continued to use VR during transportation and six (15.4%) were induced with VR. Barriers to feasibility included: interruptions to VR in 92.3% of patients, mostly by healthcare professionals; unpredictable surgery delays prolonging duration of the VR intervention (mean = 23.1 min; SD = 24.4 min; range 5-150 min); and discontinuation of VR before induction due to mask seal (n = 3) and discomfort with supine positioning (n = 2). Stakeholders were satisfied with VR, deemed it acceptable and easy to use, and would recommend it to others. VR was tolerable with no self-reported simulator sickness (CSSQ: mean = 0.01). VR showed initial clinical efficacy, with a tendency towards a decrease of mean FACES anxiety from baseline (mean = 1.5; SD = 1.1) to during VR (mean = 0.7; SD = 0.9).

Conclusions:

Overall, VR was a suitable and positively received intervention to help children cope in the perioperative setting. Areas meriting further development are strategies to minimize interruptions, optimization of the duration of VR before OR, and optimization of induction mask fit under the headset. These findings will help scale up the evaluation of VR distraction in the perioperative setting to a more definitive randomized controlled trial and will help inform its implementation.