Let kids play: Using virtual reality as a substitute for general anesthesia for minor procedures in pediatric population

Abstract

Background:

In the pediatric population, virtual reality (VR) has been used as an adjunct to augment analgesia and reduce the need for opioids. In this study, we review our experience using VR in lieu of anesthesia or sedation to enable minor procedures in children.

Methods:

A retrospective chart review study was performed on patients who presented to our institution from 2019 to 2022 for hormone implant placement, exchange, or removal with VR distraction. Demographic and procedure information was recorded. The primary outcome was successful procedure completion without requiring pharmacologic sedation or analgesia.

Results:

A total of 111 patients underwent the following minor procedures with VR and without anesthesia or sedation. Fourteen patients had multiple encounters resulting in a total of 126 encounters. The median age was 11 [6] years. 43 patients were female, 23 were female to male, 6 were non-binary, 7 were male, and 32 were male to female. 58% had private insurance. Most common diagnosis was precocious puberty (54%) followed by gender dysphoria (46%). Most common procedure was implant placement (72%). 69% of procedures were performed in the clinic and 31% in the OR. All procedures were completed without requiring the administration of additional sedation or anesthesia. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complications were recorded.

Conclusion:

VR is a feasible option that can spare children from sedation or general anesthesia for minor procedures. VR may enable minor procedures in children to be successfully performed in clinic setting.

Introduction

Significant parental anxiety surrounds the administration of general anesthesia (GA) to children. However, children often require GA or sedation for minor therapeutic and diagnostic procedures due to age-appropriate anxiety. Despite the potential risks of GA, children often require deeper sedation than adults to maintain acceptable conditions during the procedure [1]. Burn dressings, foreign body removals, laceration repairs, gynecological examinations, diagnostic imaging, fracture, or dislocation reductions, and even blood draws in children may require sedation or GA to control pain and anxiety during the procedure [2]. Sedation and general anesthesia are associated with various short-term and long-term side effects including laryngospasm, aspiration, potential neurotoxicity, and learning deficits [3, 4]. The long-term neurodevelopmental effects of general anesthesia on the pediatric brain are still being evaluated [5, 6]. Evidence suggests that repeated exposure to GA may be harmful to the developing brain [7]. However, without adequate sedation, children could experience pain and anxiety that may result in long-term emotional trauma [8, 9]. Insufficient sedation is not acceptable to physicians, nurses, patients, and parents, and may result in procedural failure [2].

Many non-pharmacologic adjuvants have been employed as adjuncts to pediatric sedation, including hypnosis, video games, and music therapy [10–13]. Virtual reality (VR) has emerged as a non-pharmacologic tool to reduce pain and anxiety. As a distraction device, it increases cognitive load and reduces the patient’s attention to aversive stimuli. VR focuses the user’s attention, instead, on a three-dimensional interaction of a computer-generated environment, thereby reducing subjective pain intensity [14–17]. Recent studies have cited the growing impact of VR on overall anxiety and pain reduction in the pediatric population undergoing a wide range of procedures such as burns, oncological care, and venous access [17–20].

In the pediatric population, VR has been mainly used as an adjuvant to augment analgesia and reduce the need for opioids [21, 22]. Although VR technology has been leveraged to improve emotional and physical distress in a variety of medical settings as an adjuvant, there is limited research on the application of VR as a complete substitute for pharmacologic anxiolysis for minor procedures [3]. We previously reported our initial experience with 28 pediatric patients who underwent minor procedures with solely VR distraction. In our pilot study, we demonstrated VR was a feasible alternative to general anesthesia (GA) or sedation for select pediatric patients undergoing minor procedures [3]. Although motion sickness, nausea, dizziness, and risk of collision have been reported as side effects of VR, no side effects were observed in the initial study [3]. Patients, parents, and proceduralists were uniformly satisfied with the experience. This pilot study was performed in the OR setting with anesthesia backup. Due to the overwhelming preference of patients and parents to have VR instead of GA for minor procedures and the safety of VR, our institution launched a minor procedures clinic using VR for distraction. The present study reports our expanded experience using VR in lieu of GA in a pediatric clinic setting without anesthesia backup.

Methods:

A retrospective chart review was performed. Pediatric patients who underwent hormone implant placement, removal, or exchange at a single academic children’s hospital between January 2019 and January 2022 were included in the study. As a continuation of the previous pilot study, the hormonal implantation procedure was chosen because it represents a typical minor surgical procedure, involves multiple surgical steps, and is a homogeneous procedure with little variation between patients. Patient eligibility for VR was evaluated at their pre-procedural visit. Patientswith a history of visual impairment, seizure disorder, claustrophobia, motion sickness, or severe anxiety disorder were excluded from the study. Patients with developmental delay and recent facial trauma were also excluded if parents/clinicians felt the children would be physically unable to wear the VR device or developmentally engage with it. Mild anxiety was not considered an absolute exclusion criterion. If patients had anxiety, particularly around medical trauma, parents would decide whether that was sufficient to defer to OR with sedation. Parental assessment of their child’s ability to tolerate VR was generally accurate. There were no instances where a procedure had to be aborted because parents made incorrect judgments.

Data from patients who underwent the procedure in the OR under VR was compared with those who were not included in our trial and underwent procedures in the OR under GA during the same time interval. The study was approved by Stanford University’s Institutional Review Board, protocol #65546. The primary outcome was successful procedure completion in the clinic setting without requiring pharmacologic sedation or analgesia. Patient demographics and procedure information were collected. Frequencies are presented using mean ± standard deviation.

Peri-procedure VR application

Patients were fitted with a mobile VR headset (Samsung Gear VR, Samsung, Seoul, South Korea). Participants selected an experience from a curated library of software content, comprised of commercially available applications and locally produced software. The applications that most patients utilized were called Pebbles the Penguin (Stanford Chariot Program, Stanford, CA) and Space Pups (Stanford Chariot Program, Stanford, CA). In Pebbles the Penguin, participants engaged in a snowy world as a penguin luging down a landscape, collecting colorful pebbles along the way (video 1). In Space Pups, participants fly through a fantasy space world while controlling a puppy who is flying through space-eating treats. Both applications are available to license at no cost through a non-profit called Invincikids (San Bruno, CA). These applications were designed to increase the cognitive load (visual or auditory stimuli) and decrease anxiety during medical procedures. They use a no-fail state, where the experience continues indefinitely.

Procedure narrative:

Upon patient check-in, topical lidocaine cream is applied to the skin. A Child Life Specialist or clinic medical assistant briefly introduced the patients and families to VR and assisted with the VR technology as needed throughout the case (Fig. 1). Once the VR experience begins, the patient lies supine with the implant arm extended. The manufacturer provides a kit for hormone implantation which includes a #15 scalpel, the implant insertion tool, a 20 mL vial of 1% lidocaine with epinephrine, and other minor procedure supplies. After a sterile field is established, a wheal of local anesthetic is made at the desired location of implant insertion. Commercially available aerosolized cold spray is then used to provide additional analgesia while 3–5 cc of buffered lidocaine is infiltrated along the intended subcutaneous path of the implant. A 5–10 mm incision is then made, and blunt dissection is performed with a mosquito. The implant is placed using the insertion tool. The incision is closed with an absorbable suture. A similar amount of local anesthetic is used for hormone implant exchange and removal.

Fig.1:

Clinic visit flow

Statistical analysis:

Numerical values were formatted as Median [IQR]. Considering relatively normal distribution of the data, Student’s t-test was conducted to compare the surgical time between the two groups and p-value < 0.05 was considered statistically significant.

Results:

From January 2019 to January 2021, a total of 111 patients underwent hormone implant insertion, exchange, or removal under VR without GA or sedation in our academic children’s hospital. Fourteen patients had multiple encounters during the study period resulting in a total of 126 encounters. For data analysis, each anesthesia exposure per patient was considered a separate event. Patients’ age at the time of the procedure was 11 [6] years. Seventy-two patients were assigned female at birth, 23 of whom identified as male at the time of the procedure, and 6 of whom identified as non-binary. Thirty-nine patients were assigned male at birth, 32 of whom identified as female at the time of the procedure. In 72 (58%) procedures, patients had private insurance. The most common diagnosis was precocious puberty (54%) followed by gender dysphoria (46%). The most common procedure was hormone implant placement (72%) followed by exchange (21%) and removal (7%). A total of 88 (69%) procedures were performed in the clinic and 38 procedures were performed in the OR. Among those procedures that were performed in the OR, in 25 procedures, anesthesiology backup was present. No anesthesia backup was considered for the remainder of the patients (Fig. 2). Five surgeons performed the procedures with VR distraction. All procedures were performed in the usual manner as they would be done under GA, and no additional training was required for surgeons to perform the procedures under VR distraction. All procedures were completed without requiring sedation or GA. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complication was recorded. Post-procedure, in one patient, the implant had eroded through the skin, and in another patient, the implant broke and required replacement. One patient complained of persistent pain at the insertion site and one patient developed a surgical site infection requiring antibiotic therapy.

Fig. 2:

Patient demographics and procedure characteristics

In 2 out of the 14 patients who underwent more than one procedure, the subsequent surgery was performed under GA. One of these patients required implant removal and had significant weight gain since implant placement so the implant was no longer palpable. The surgeon was unable to find the implant during the initial surgery, which was performed under VR distraction, and hence, GA was requested by the surgeon for wider exposure in the subsequent surgery. The second patient received GA for the subsequent surgery since the surgeon was not aware of the possibility of performing the procedure under VR distraction at the institution.

During the same period of time, 42 patients were identified who underwent these minor procedures in the OR under GA. In this group, patients’ age at the time of the procedure was 8 [4.75] years. Thirty-five patients were assigned female at birth, 6 of whom identified as male at the time of the procedure, and 1 of whom identified as non-binary. Seven patients were assigned male at birth, 4 of whom identified as female at the time of the procedure. The most common diagnosis was precocious puberty (76%) followed by gender dysphoria (23%). The most common procedure was hormone implant placement (67%) followed by exchange (33%) and removal. All these patients received NSAIDs and crystalloid solutions in the perioperative course. In the OR, 59.5% of the patients received Propofol, 31% received Fentanyl, 19% received Midazolam, 38% received Dexmetomidine, and 71.4% received inhaled anesthetics. The procedure time in this group was 28 [10.75] minutes which was significantly longer than the group who underwent the procedure in OR under VR (23 [13.5] minutes, (p:004)). Procedure time for procedures performed under VR in the clinic setting was not available. However, all clinic appointments were designated as 30-minute clinic visits. Recovery time in the GA group was 78 [42.5] minutes which was also significantly longer than the VR group (23.5 [8.5] minutes (p<001)). Patients who underwent surgery in the clinic setting left the clinic immediately following the conclusion of the procedure.

Discussion:

Minor procedures are often anxiety-provoking and may be painful for children [2]. Anxious children may be uncooperative and even obstructive to the successful completion of the procedure [2, 15]. Patients with untreated pain and anxiety during medical procedures might develop short or long-term sequelae, including needle phobia, post-traumatic stress disorder, and lack of trust in the healthcare system [14, 15]. Many pharmacological and nonpharmacological approaches have been proposed to help reduce patients’ pain and anxiety perioperatively or during minor procedures [13]. VR has been employed as a nonpharmacologic tool for adults and children by distracting patients’ attention from aversive stimuli [14, 17, 23–27]. With the increasing availability of VR headsets, devices typically cost several hundred dollars. Coupled with no-cost software licensing and clinical user guides, available from companies such as Invincikids, Inc. (San Bruno, CA), there are very few barriers to clinical implementation beyond desire. As a consumer device, they are technically straightforward to operate, and medical assistants and child life specialists are prime allied health providers who can serve as implementation specialists. Although VR has been used as an adjuvant for premedication or during minor procedures, there are limited studies to support the use of VR alone as an anxiolytic [3, 16].

Our initial pilot study on 28 patients demonstrated the feasibility of using VR alone as an anxiolytic modality for minor procedures [3]. All patients in the pilot study completed the procedure without GA, sedation, or IV catheter placement, and most were cooperative with the healthcare provider’s instructions during the procedure. Compared to those who underwent the procedures under GA or sedation, those who received VR had a significantly shorter recovery time. The technology was favored by parents, patients, and healthcare providers [3]. Although our team aimed to perform a randomized clinical trial to compare the outcomes and better identify the patients who most benefit from VR, most of the patients and their parents were unwilling to be enrolled in the study and risk GA. Almost all potential participants opted for the use of VR. As a result, a minor procedures clinic using VR staffed by a surgeon, a nurse, and a child life specialist was started at our institution. Based on previous studies on the placement or removal of hormone implants in the clinic setting and our successful pilot experience, no oral anxiolysis or analgesia was provided in the clinic [3, 28]. This study presents our experience to date with 126 hormone implant procedures successfully performed under VR distraction alone. All patients completed the procedure without any complications. None of the patients required intravenous catheter placement or sedation.

Despite the current trend towards avoiding or minimizing GA and sedation during minor procedures, there is no widely accepted standard of care for children. Given the reduction in the cost of VR, its ease of use, and increased commercial availability, it is a reasonable tool to reduce pain and anxiety in the hospital setting [17]. Following the previous pilot study, the current study on a larger patient population in the clinic setting not only demonstrates the feasibility of VR as a replacement for sedation or GA for minor procedures, but also illustrates the preference for this technique among children, parents, and providers. Due to the overwhelmingly positive feedback from the pilot study, no further surveys were employed in the current study. Procedure time was not recorded in those who performed in the clinic, but the procedure time in those who received the procedure in the OR under VR was shorter than those who received GA. Pain scores were not recorded in this study; however, our pilot study indicated no difference in the average post-procedure pain scores between the VR and non-VR groups.

It is important to mention that not all available VR games and experiences are suitable for all children or procedures. No-fail-state games with adjustable horizons are appropriate to accommodate various procedure times and positions. Provider-controlled features also help to adjust the auditory or visual stimuli as indicated [3].

Hormone implant procedures were selected for this study as a suitable minor procedure that includes incision and suturing [28]. Given the favorable results of this study, the replacement of GA or sedation with VR distraction can be expanded to other procedures including tube exchanges, nerve block, lumbar puncture, incision and drainage, biopsies, or minor endoscopic exams. They may also be a useful adjunct for consultative clinic visits with patients who have difficult office visits due to underlying autism or anxiety disorders [13, 27].

Conclusion:

VR is cost-effective and easy to use with a low side-effects profile. VR has demonstrated in our expanded study the potential to spare children from sedation or GA. Developing minor procedure clinics and appropriate VR experiences would be a worthy investment for hospitals to optimize patient care and decrease the utilization of hospital resources including OR and anesthesia teams.

Supplementary Material

1

Video one: Pebbles the Penguin VR experience.

Highlights:

• VR is a feasible option that can spare children from sedation or general anesthesia in minor procedures.

• VR is a key tool that may facilitate successful minor procedure clinics for children.

Abbreviations:

GA

general anesthesia

VR

Virtual Reality