BOSTON – 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 undergoing hand surgery typically receive regional anesthesia to block pain before the procedure, as well as monitored anesthesia care (MAC) during the operation. MAC typically consists of a sedative given intravenously — such as propofol — to keep patients feeling drowsy and calm during procedures, but alert enough to follow instructions as needed. However, too much sedation can lead to low blood pressure, upper airway obstruction, and potentially serious complications such as stroke, heart attack, or respiratory failure.
In a new attempt to reduce the risks of excessive sedation, physician-researchers at Beth Israel Deaconess Medical Center (BIDMC) conducted a randomized controlled trial to determine if virtual reality immersion can minimize the need for sedatives during surgery. hand without having a negative impact on patient satisfaction. The team studied adults undergoing hand surgery who were randomized to receive either virtual reality (VR) immersion during the procedure in addition to the usual MAC, or the usual 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-anaesthetic care unit (PACU). 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, MD, MPH, anesthetist in the Department of Anesthesia, Critical Care and Pain Medicine at BIDMC. “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 the programming of their choice from several immersive 360-degree VRs. environments designed to promote relaxation and calm, such as a meadow, a forest or a mountain top. For both groups, additional anesthetics and/or analgesics could be administered either at the request of the patient or at the discretion of the anesthesiologist based on clinical judgment. 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 propofol 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 follow-up questionnaires administered in the recovery room 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. There were also no significant differences between the groups’ PACU pain scores and perioperative opioid doses. Strikingly, however, the VR group exited PACU after their surgery an average of 22 minutes earlier than their control group counterparts. One month after surgery, no difference was found between the groups in their functional outcomes with respect to hand function.
“Our trial is novel in that it is the first to report a significant reduction in sedative dosage with VR immersion during hand surgery in adults,” said O’Gara, who is also an assistant professor in anesthesia at Harvard Medical School. “By using virtual reality immersion, the potential harm of unnecessary sedation can be avoided without compromising patient comfort during hand surgery. Additionally, we saw that patients in the VR group exited the PACU 22 minutes earlier than control patients. A reduction in recovery room stay could help optimize perioperative efficiency if the virtual reality technique were used more widely.
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 Gassangwa 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 funded by the American Society of Anesthesiologists Foundation for Education and Research in Anesthesia Mentored Research Training Grant; 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.
About Beth Israel Deaconess Medical Center
Beth Israel Deaconess Medical Center is a patient care, teaching, and research affiliate of Harvard Medical School and consistently ranks among the national leaders among independent hospitals funded by the National Institutes of Health. BIDMC is the official hospital of the Boston Red Sox.
Beth Israel Deaconess Medical Center is part of Beth Israel Lahey Health, a health care system that brings together academic medical centers and teaching hospitals, community and specialty hospitals, more than 4,800 physicians and 36,000 employees in a common mission to expand access to quality care. and to advance the science and practice of medicine through groundbreaking research and education.
Publication date of articles
Sep 21, 2022
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