Tuesday March 2, 2021
In the March issue of A&A, Jung et al. report a randomized, controlled study to determine whether virtual reality (VR) distraction decreases patient anxiety prior to, and during, mask induction of anesthesia. The authors studied 70 children, 5–12 years of age scheduled for elective surgery. The patients assigned to the VR group (n=33) were assigned to wear the VR headset immediately before induction in the operating room, whereas the control group (n=37) 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. Secondary outcomes included postinduction parental anxiety measured by the State-Trait Anxiety Inventory, patient induction compliance, and parental satisfaction. No patients received preoperative anxiolytic medication, and nearly all children had a parent present during the induction.
Median mYPAS scores from baseline to time of induction were significantly lower in the VR group vs control (0.0 [interquartile range 0.0–5.0] vs 13.3 [interquartile range 5.0–26.7], [97.5% confidence interval, 3.7–23.0]; P < .0001). Twenty-seven patients (73.0%) in the control group had an increase in anxiety from preoperative holding area to OR, while 6 patients (18.2%) in the VR group had increased anxiety (P < .0001). Thirty-two (86.5%) patients in the control group had increased anxiety during induction, as opposed to only 11 (33.3%) patients in the VR group (P < .0001).
The secondary outcomes of pediatric induction compliance, perioperative parental anxiety as measured by the STAI, and parental satisfaction did not show statistically significant differences.
Although these results were quite predictable, this study needed to be done, especially by a group that has experience using VR for distraction. Why is preoperative anxiolysis so important? As the authors rightly point out, previous work in this area has correlated preoperative or induction behavior with postoperative behavioral changes, such as separation anxiety, nightmares, and eating disorders, to name only a few. I wonder whether VR will now be used in all their elective pediatric cases. Since the authors have convincingly shown its superiority, is it unethical to omit it?
The real test, however, will be to prove whether or not VR is superior to anxiolytic premedication (e.g., midazolam) and likewise, prevents postoperative sequelae. As I pointed out in a 2011 editorial I wrote on this subject in Anesthesiology (anyone who finds all the literary references I snuck into that editorial gets a special shoutout in a future PAAD), postoperative maladaptive changes occur when the child retains a memory of the trauma associated with strangers that physically restrain them and force a smelly mask onto their face. Who wouldn’t have nightmares after that traumatic experience? The reason midazolam works so well is its ability to cause amnesia of the stressful event, or at least, a less stressful remembrance of that event. Or perhaps, the midazolam inhibits the transfer of the event from short- to long-term memory in the brain. Whatever the mechanism, VR will have to achieve the same, and the results, thus far, look promising.