Forget the sedatives, I'll take VR - Harvard Gazette

Forget the sedatives, I’ll take VR – Harvard Gazette

With conditions such as carpal tunnel syndrome and osteoarthritis on the rise, American hand surgeons perform more than half a million procedures each year. Patients typically receive regional anesthesia to block pain before the procedure, as well as monitored anesthesia care, or MAC, during the operation.

MAC usually consists of an intravenously administered sedative such as propofol to make patients feel drowsy and calm during procedures, but alert enough to follow instructions. Too much sedation, however, can lead to low blood pressure, upper airway obstruction, and serious complications such as stroke, heart attack, or respiratory failure.

In a new attempt to reduce the risks of excessive sedation, physician-scientists at Beth Israel Deaconess Medical Center conducted a randomized controlled trial to determine if virtual reality immersion can minimize the need for sedatives during hand surgery without decrease patient satisfaction. The team studied adults who were randomized to receive either VR immersion during the procedure in addition to MAC, or MAC alone. They found that virtual reality immersion during hand surgery led to significant reductions in sedative doses as well as postoperative lengths of stay in the post-anesthesia care unit. Their work is published in PLOS ONE.

“With the increase in the amount of time people spend at the keyboard combined with our aging population, there is a projected increased need for routine elective hand surgeries,” said lead author Brian P. O’Gara, anesthetist and assistant professor at Harvard. Medicine School. “Optimizing care for these patients will undoubtedly require a change in anesthetic practices. The purported benefit of virtual reality in managing patients with pain or anxiety is to provide an immersive experience capable of distracting the mind from the treatment of the inconveniences associated with surgery.

O’Gara and colleagues enrolled 34 adults who underwent hand surgery with regional anesthesia at BIDMC between December 2018 and August 2019. Patients who received virtual reality wore noise-cancelling headphones and earphones and selected programming from their choice of several immersive virtual reality environments designed to promote relaxation and calm, such as a meadow, a forest or a mountain peak. For both groups, additional anesthetics or analgesics could be administered either at the request of the patient or at the discretion of the anesthesia provider. No investigator was assigned to be the anesthesia provider for study participants in either group, and no study team members were present in the operating room. to conduct research activities for patients in the control group.

The scientists’ results revealed that patients in the VR group received significantly less propofol than those in the control group – a median of 260 mg less per case than patients in the usual care group. Notably, only four of the 17 patients in the VR group received propofol during their procedure, while all patients in the control group received the sedative. However, significantly more patients in the VR group received additional local anesthesia by the surgeon than in the control group, suggesting that preoperative nerve block is very important for the success of the VR technique.

In questionnaires administered after surgery, patient self-reported results revealed no significant differences between the VR and control groups in terms of overall satisfaction. Additionally, patients in both groups reported that their pain was well controlled and they felt relaxed during their surgery. Members of the VR group were discharged from the hospital an average of 22 minutes earlier than their counterparts in the control group. One month after surgery, there was no difference in hand function between the groups.

“Our trial is novel in that it is the first to report a significant reduction in virtual reality immersion sedative dosage during hand surgery in adults,” O’Gara said. “Through virtual reality immersion, potential harm from unnecessary sedation can be avoided without compromising patient comfort during hand surgery.”

Co-authors included first author and corresponding author Adeel A. Faruki of the University of Colorado Hospital; Nadav Levy, Sam Proescel, Valerie Banner-Goodspeed and Tamara D. Rozental of BIDMC; Thy B. Nguyen of the University of Colorado School of Medicine; Doris-Vanessa Gasangwa of St. George’s University School of Medicine; Jessica Yu of Case Western Reserve University School of Medicine; Victoria Ip of Nova Southeastern School of Osteopathic Medicine; Marie McGourty of the University of Massachusetts, Boston; Galina Korsunsky of Spectrum Healthcare Partners; Victor Novack of Soroka University Medical Center; and Ariel L. Mueller of Massachusetts General Hospital.

This work was supported by a Research Training Fellowship sponsored by the American Society of Anesthesiologists Foundation for Education and Research in Anesthesia. XRHealth provided free access to software and hardware required for the trial. Additional support for investigator time, research staff, and equipment was provided by the BIDMC Center for Anesthesia Research Excellence.

O’Gara is a consultant for Sedana Medical. Korsunsky has a business affiliation with Spectrum Healthcare Partners as an employee. All other authors report no conflicts of interest.

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