Digital Sedation in Interventional Radiology: Reducing Pain and Anxiety Through Virtual Reality During Peripherally Inserted Central Catheter Placement and Fine Needle Aspiration Thyroid Biopsy
Clinical question
Does the use of virtual reality (VR) as a non-pharmacologic adjunct have analgesic and anxiolytic effects during Peripherally Inserted Central Catheter (PICC) placement and Fine Needle Aspiration (FNA) thyroid biopsy?Take away point
Implementation of VR as a non-pharmacologic adjunct can reduce pain during some interventional radiology procedures; therefore, showing promise as an alternative to pharmacological approaches.Reference
Schaake, R., Leopold, I., Sandberg, A., Zenk, B., Shafer, L., Yu, D., Lu, X., Theingi, S., Udongwo, A., Cohen, G. S., & Maresky, H. S. (2024). Virtual reality for the management of pain and anxiety for IR procedures: A prospective, randomized, pilot study on Digital Sedation. Journal of Vascular and Interventional Radiology, 35(6), 825–833. https://doi.org/10.1016/j.jvir.2024.03.004Click here for abstract
Study design
Prospective, single-center randomized controlled trial with 107 patients.Funding Source
This study was supported by the Lewis Katz School of Medicine at Temple University.Setting
Academic setting, Lewis Katz School of Medicine at Temple University.Figure
Figure 1(a) Image of virtual reality tropical island environment used in trials. (b) Image of study participant viewing virtual reality during peripherally inserted central catheter placement.
Figure 4(a) Estimation plots for paired data of individual VAS pain scores before and after thyroid biopsy for individuals randomized to SOC (n = 22) vs SOC+VR (n = 25). (b) Estimation plots for individual VAS anxiety scores for before and after thyroid biopsy for individuals randomized to SOC (n = 22) vs SOC+VR (n = 25). Tufte slope graphs are presented for each patient, connecting pre- and postprocedural VAS scores. Mean difference and 95% confidence intervals bars are plotted below each panel. PICC = peripherally inserted central catheter; SOC = standard of care; VAS = visual analog scale; VR = virtual reality.
Schaake et al. examined the use of virtual reality (VR) as a form of “digital sedation” to reduce pain and anxiety during Interventional Radiology (IR) procedures that typically do not require pharmacologic sedation, such as peripherally inserted central catheter (PICC) placement and fine-needle aspiration (FNA) thyroid biopsies. A prospective, single center randomized controlled trial was conducted with a sample size of 107 patients assigned to either a Standard of Care or Standard of Care plus Virtual Reality. The PICC cohort consisted of 59 patients with a median age of 53.1, while the thyroid biopsy cohort consisted of 48 patients with a median age of 60.1. Of note, the following groups of patients were excluded from the study: declining to participate, inability to provide consent, emergency procedures, administration of general anesthesia/moderate sedation, visual/hearing deficits, pregnancy, current prisoner status, nerve/sensory deficits over the area of procedure, or coronavirus disease 2019–positive status.
The VR procedure utilized the “Emmarye” (VRAL, Philadelphia, Pennsylvania) environment where the patient viewed a tropical environment with a sunset sky and ambient audio of the ocean and seagulls. A fairy would also appear engaging users in breathing exercises and giving reminders to remain still. Participants in the study completed an assessment of anxiety and pain using visual analog scales both pre- and post-procedure. Heart rate and blood pressure were also obtained during the procedure. Statistical analysis included a one-way ANOVA comparing the two groups with respect to pain and anxiety scores, ultimately indicating that VR significantly reduced pain scores during fine needle aspiration of the thyroid. Additionally, a trend was observed without statistical significance showing reduced anxiety during thyroid biopsies, as well as reduced pain and anxiety during peripherally inserted central catheter placement. Schaake et al. concluded that VR could be implemented to alleviate patient pain and anxiety during minimally invasive IR procedures, without increased procedural duration or risks of adverse events. They also contextualized these findings with other studies demonstrating the efficacy of using VR during simple procedural interventions in medicine, such as reducing pediatric patient’s anxiety and pain during orthopedic cast removal.
As healthcare continues to integrate technological advancements, the use of virtual reality to improve patient comfort is an intriguing area worthy of exploration. Patients often experience pain and anxiety around procedures. While pharmacologic anxiolytics and analgesics play an important role in procedural care, their adverse effects, especially in an epidemic of pain medication misuse and overuse, should not be overlooked. Therefore, this study’s investigation on non-pharmacologic methods to improve patient comfort during interventional radiology procedures is illuminating. The methodology incorporated a unique healthcare-oriented VR environment, established scales for pain and anxiety measurements, and appropriate analytic statistics. The results, though limited by small sample size, two procedures typically not requiring sedation, and missed opportunities of capturing granular procedural details, are promising for the use of VR for pain and anxiety control peri-procedurally.
Nevertheless, there are several important considerations or even obstacles to potential wider clinical application of VR. First, the initial cost of VR equipment and need for continual updates may be expensive. Second, the scope of VR is limited by procedure type. Certain procedures require patient feedback, or the patient may need to be physically adjusted into a position that could be obstructed by the VR headsets. Wearing VR headsets for lengthy procedures can also be uncomfortable for some patients and issues like battery life and technological difficulties may arise. Finally, patients might experience VR-related eye strain, headaches, or motion sickness. With motivated investments from the industry and continued technological advancements, however, these issues will be of ever decreasing concern.
This study offers an insightful view on the potential for advanced technology in patient care. Virtual Reality offers exciting possibilities in medicine, but more research is needed to ensure maximization of the benefits and minimization of adverse events. Ultimately, Schaake et al. demonstrate a promising outlook on how technology advances in the reality-virtuality continuum can improve the tolerability of health care interventions.
Post Author
Shabaz Khan, B.A
M.D. Candidate, Class of 2027
University of Massachusetts Chan Medical School
@shabaz_khan11
Figure 4(a) Estimation plots for paired data of individual VAS pain scores before and after thyroid biopsy for individuals randomized to SOC (n = 22) vs SOC+VR (n = 25). (b) Estimation plots for individual VAS anxiety scores for before and after thyroid biopsy for individuals randomized to SOC (n = 22) vs SOC+VR (n = 25). Tufte slope graphs are presented for each patient, connecting pre- and postprocedural VAS scores. Mean difference and 95% confidence intervals bars are plotted below each panel. PICC = peripherally inserted central catheter; SOC = standard of care; VAS = visual analog scale; VR = virtual reality.
Summary
Schaake et al. examined the use of virtual reality (VR) as a form of “digital sedation” to reduce pain and anxiety during Interventional Radiology (IR) procedures that typically do not require pharmacologic sedation, such as peripherally inserted central catheter (PICC) placement and fine-needle aspiration (FNA) thyroid biopsies. A prospective, single center randomized controlled trial was conducted with a sample size of 107 patients assigned to either a Standard of Care or Standard of Care plus Virtual Reality. The PICC cohort consisted of 59 patients with a median age of 53.1, while the thyroid biopsy cohort consisted of 48 patients with a median age of 60.1. Of note, the following groups of patients were excluded from the study: declining to participate, inability to provide consent, emergency procedures, administration of general anesthesia/moderate sedation, visual/hearing deficits, pregnancy, current prisoner status, nerve/sensory deficits over the area of procedure, or coronavirus disease 2019–positive status.
The VR procedure utilized the “Emmarye” (VRAL, Philadelphia, Pennsylvania) environment where the patient viewed a tropical environment with a sunset sky and ambient audio of the ocean and seagulls. A fairy would also appear engaging users in breathing exercises and giving reminders to remain still. Participants in the study completed an assessment of anxiety and pain using visual analog scales both pre- and post-procedure. Heart rate and blood pressure were also obtained during the procedure. Statistical analysis included a one-way ANOVA comparing the two groups with respect to pain and anxiety scores, ultimately indicating that VR significantly reduced pain scores during fine needle aspiration of the thyroid. Additionally, a trend was observed without statistical significance showing reduced anxiety during thyroid biopsies, as well as reduced pain and anxiety during peripherally inserted central catheter placement. Schaake et al. concluded that VR could be implemented to alleviate patient pain and anxiety during minimally invasive IR procedures, without increased procedural duration or risks of adverse events. They also contextualized these findings with other studies demonstrating the efficacy of using VR during simple procedural interventions in medicine, such as reducing pediatric patient’s anxiety and pain during orthopedic cast removal.
Commentary
As healthcare continues to integrate technological advancements, the use of virtual reality to improve patient comfort is an intriguing area worthy of exploration. Patients often experience pain and anxiety around procedures. While pharmacologic anxiolytics and analgesics play an important role in procedural care, their adverse effects, especially in an epidemic of pain medication misuse and overuse, should not be overlooked. Therefore, this study’s investigation on non-pharmacologic methods to improve patient comfort during interventional radiology procedures is illuminating. The methodology incorporated a unique healthcare-oriented VR environment, established scales for pain and anxiety measurements, and appropriate analytic statistics. The results, though limited by small sample size, two procedures typically not requiring sedation, and missed opportunities of capturing granular procedural details, are promising for the use of VR for pain and anxiety control peri-procedurally.
Nevertheless, there are several important considerations or even obstacles to potential wider clinical application of VR. First, the initial cost of VR equipment and need for continual updates may be expensive. Second, the scope of VR is limited by procedure type. Certain procedures require patient feedback, or the patient may need to be physically adjusted into a position that could be obstructed by the VR headsets. Wearing VR headsets for lengthy procedures can also be uncomfortable for some patients and issues like battery life and technological difficulties may arise. Finally, patients might experience VR-related eye strain, headaches, or motion sickness. With motivated investments from the industry and continued technological advancements, however, these issues will be of ever decreasing concern.
This study offers an insightful view on the potential for advanced technology in patient care. Virtual Reality offers exciting possibilities in medicine, but more research is needed to ensure maximization of the benefits and minimization of adverse events. Ultimately, Schaake et al. demonstrate a promising outlook on how technology advances in the reality-virtuality continuum can improve the tolerability of health care interventions.
Post Author
Shabaz Khan, B.A
M.D. Candidate, Class of 2027
University of Massachusetts Chan Medical School
@shabaz_khan11
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