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Eur J Anaesthesiol. 2019 Oct;36(10):728-737. doi: 10.1097/EJA.0000000000001059.

Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial.

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From the Department of Child and Adolescent Psychiatry/Psychology (RE, BD, JMB, MHJH, JSL, EMWJU), Department of Anaesthesiology, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands (LMS), Department of Anaesthesia, ZNA Middelheim, Queen Paola Children's Hospital, Antwerp, Belgium (JMB), Dutch Craniofacial Centre (MPvdS), Department of Otorhinolaryngology and Head and Neck Surgery (MPvdS), Department of Oral and Maxillofacial Surgery (EMS), Intensive Care and Department of Paediatric Surgery, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam (RMHW), Research Institute of Child Development and Education, University of Amsterdam (EMWJU), Academic Centre for Child Psychiatry De Bascule/Department of Child and Adolescent Psychiatry, Academic Medical Centre, Amsterdam, The Netherlands (EMWJU).



Pre-operative anxiety in children is very common and is associated with adverse outcomes.


The aim of this study was to investigate if virtual reality exposure (VRE) as a preparation tool for elective day care surgery in children is associated with lower levels of anxiety, pain and emergence delirium compared with a control group receiving care as usual (CAU).


A randomised controlled single-blind trial.


A single university children's hospital in the Netherlands from March 2017 to October 2018.


Two-hundred children, 4 to 12 years old, undergoing elective day care surgery under general anaesthesia.


On the day of surgery, children receiving VRE were exposed to a realistic child-friendly immersive virtual version of the operating theatre, so that they could get accustomed to the environment and general anaesthesia procedures.


The primary outcome was anxiety during induction of anaesthesia (modified Yale Preoperative Anxiety Scale, mYPAS). Secondary outcomes were self-reported anxiety, self-reported and observed pain, emergence delirium, need for rescue analgesia (morphine) and parental anxiety.


A total of 191 children were included in the analysis. During induction of anaesthesia, mYPAS levels (median [IQR] were similar in VRE, 40.0 [28.3 to 58.3] and CAU, 38.3 [28.3 to 53.3]; Pā€Š=ā€Š0.862). No differences between groups were found in self-reported anxiety, pain, emergence delirium or parental anxiety. However, after adenoidectomy/tonsillectomy, children in the VRE condition needed rescue analgesia significantly less often (55.0%) than in the CAU condition (95.7%) (Pā€Š=ā€Š0.002).


In children undergoing elective day care surgery, VRE did not have a beneficial effect on anxiety, pain, emergence delirium or parental anxiety. However, after more painful surgery, children in the VRE group needed rescue analgesia significantly less often, a clinically important finding because of the side effects associated with analgesic drugs. Options for future research are to include children with higher levels of anxiety and pain and to examine the timing and duration of VRE.


Netherlands Trial Registry: NTR6116.

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