Undergoing an operation is a major stress for both children and their families, with up
to 50% of the children reported to have significant perioperative anxiety . High levels
of perioperative anxiety in children manifest as tension, irritability and increased
autonomic nervous system activity; and are associated with a multitude of adverse
clinical outcomes, including increased postoperative analgesia requirement, increased
postoperative emergence delirium, increased postoperative behavioural changes (e.g.
nightmares, postoperative separation and general anxiety, eating problems that can
persist up to 2 weeks after surgery). Furthermore, it impacts patient and parental
satisfaction, creating an overall negative experience for families and staff.
The multifaceted risk factors of perioperative anxiety in children warrant a multi-modal
array of tools up anaesthesiologists' sleeves to tailor for different children's needs
based on age, understanding of instructions, and temperament . While pharmacological
anxiolytics, e.g. Dexmedetomidine and Midazolam, are commonly deployed and effective, it
has its limitations, such as time to effect, patient's age, as well as paradoxical
agitation reported up to 10% for Midazolam, as well as taking away a learning opportunity
for children to cope with stress. Common non-pharmacological approaches include parental
presence during induction of anaesthesia, distraction techniques, and educational
approaches.
Traditional educational approaches often involve providing information to children and
parents/legal guardians by written pamphlets, either physical or video tour of the
operating room, recovery area, and orientation of medical equipment. With the advance of
technology, children are often familiar and easily engaged with technological devices,
including smart phones, tablets, video games, and even immersive virtual reality (VR). VR
is increasingly utilized in clinical setting, providing a fun and engaging educational
experience for children.
VR utilizes a head-mounted display with visual, auditory and tactile stimuli to simulate
a fully immersive 3-dimensional environment. Its application in the paediatric
perioperative setting can be either as distraction during painful procedures or during
induction of anaesthesia, or as an exposure tool in preoperative education. A
meta-analysis of the effect of VR on preoperative anxiety shows a significant reduction
of preoperative anxiety in paediatric patients. Previous study utilized a famous cartoon
character in the VR preoperative educational video and showed significant reduction in
preoperative anxiety when compared to children receiving information through conventional
means. This benefit of VR exposure in reducing preoperative anxiety is not only evident
in numerous studies measuring anxiety score, but also demonstrated in studies measuring
salivary cortisol concentration.
In a joint project involving the Department of Computing of Hong Kong Polytechnic
University, the Department of Computer science Center for Innovative Applications of
Internet and Multimedia Technologies of the City University of Hong Kong and the Hong
Kong Children's Hospital (HKCH), an immersive VR operating theatre tour will be designed
as part of preoperative education for children. A simulation of the perioperative journey
in HKCH operating theatre will be created to help children form realistic expectations of
their perioperative journey, and virtual exposure of different medical equipment helps
children cope with their worries for the anticipated procedures. Parents/legal guardians
will be able to monitor the VR experience on tablets via the monitoring software, which
displays what the children see in VR. Given the fact that the capacity of conventional
approaches, e.g. child-play involvement by child-life specialists are hugely limited now
due to COVID pandemic, such a VR-enabled approach may help to alleviate patient's
anxiety.
