Virtual reality for paediatric needle procedural pain. Dr Evelyn Chan

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1 Virtual reality for paediatric needle procedural pain Dr Evelyn Chan

2 Needle pain is common and undermanaged Needles Common 1 Most feared 1,2 Control of pain and anxiety crucial for successful procedures 3 Suboptimally controlled 1,2,3 1. Friedrichsdorf et al. Hosp Pediatrics Shomaker et al. Hosp Pediatrics Krauss et al. Lancet 2016

3 Virtual reality (VR)

4 Literature is generally at high risk of bias Study Procedure n = Randomisation Allocation concealment Gershon 2004 Port access 59 Gold 2006 IV cannula 20 Gold 2017 Venepuncture 143 Wolitzky 2005 Port access 20? +? Selective reporting +? - +??? + - Chan et al. PLoSONE 2018

5 Meta-analysis suggests needle pain benefit Chan et al. PLoSONE 2018

6 Aims 1. Primary: Determine whether VR reduces pain associated with needle procedures 2. Secondary: Assess whether VR reduces Anxiety Need for restraint Qualitative analysis Prospective registration ANZCTR: ACTRN Chan et al. Under review

7 VR development INTRODUCTION PREPARE IDENTIFY, INSERT BLOOD DRAW WRAP UP ID and test check Set up equipment Tourniquet, find vein Draw blood Apply bandaid Insert needle Remove needle Label tubes INTRODUCTION RELAXATION FISH FEEDING DOLPHIN RIDE WRAP UP Start VR experience Guided relaxation Keeping still Keeping still Positive reinforcement Orient to VR Deep breathing Re-framing sensations Immersive distraction

8 Study design Standard of care Screening Baseline measures Randomisation Post procedure measures VR Monash Human Research Ethics Committee: HREC/17/MonH/15 Prospective registration ANZCTR: ACTRN

9 Study design Standard of care Screening Baseline measures Randomisation Post procedure measures Inclusion criteria 4-11 years old IVC or venepuncture Able to complete measures Informed consent / assent Exclusion criteria Significantly unwell Unable to complete measures (e.g. significant disability) VR Monash Human Research Ethics Committee: HREC/17/MonH/15 Prospective registration ANZCTR: ACTRN

10 Primary outcome: pain (FPS-R) Standard of care Screening Baseline measures Randomisation Post procedure measures VR Monash Human Research Ethics Committee: HREC/17/MonH/15 Prospective registration ANZCTR: ACTRN Hicks et al. Pain 2001

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12 Group were balanced at baseline ED SOC (n= 59) VR (n= 64) Pathology SOC (n= 66) VR (n= 63) Age Sex 46% F 54% M Baseline pain % F 55% M Age Sex 46% F 54% M Baseline pain % F 60% M Topical local anaesthetic Procedure 85% 89% 20% venepunc 80% IVC 17% venepuc 83% IVC Topical local anaesthetic 14% 13% Procedure 100% venepunc 100% venepunc

13 VR reduces pain in ED and pathology ED Pathology C h a n g e in p a in fro m b a s e lin e 0 C h a n g e in p a in fro m b a s e lin e S ta n d a r d o f c a r e V ir tu a l r e a lity Mean difference: units (p=0.018) S ta n d a r d o f c a r e V ir tu a l r e a lity Mean difference units (p=0.034)

14 VR reduces pain in ED and pathology ED Pathology C h a n g e in p a in fro m b a s e lin e 0 C h a n g e in p a in fro m b a s e lin e S ta n d a r d o f c a r e V ir tu a l r e a lity Mean difference: units (p=0.018) S ta n d a r d o f c a r e V ir tu a l r e a lity Mean difference units (p=0.034) Multivariate linear regression Baseline pain, age, sex, topical local anaesthetic, prior needle exposure (p=0.03) (p=0.019)

15 VR reduced anxiety ED Pathology C h a n g e in a n x ie ty fro m b a s e lin e 0 C h a n g e in a n x ie ty fro m b a s e lin e S ta n d a r d o f c a r e V ir tu a l r e a lity S ta n d a r d o f c a r e V ir tu a l r e a lity Mean difference: units (p=0.011) Mean difference: units (p=0.016)

16 VR reduces the need for restraint ED Pathology % 5 0 % S ta n d a r d o f c a r e V ir tu a l r e a lity 0 S ta n d a r d o f c a r e V ir tu a l r e a lity 2 o r m o re p e o p le re s tra in in g 0 o r 1 p e rs o n re s tra in in g No restraint or single-person restraint in 51% with SOC vs 83% with VR (p=0.0002) 2 o r m o re p e o p le re s tra in in g 0 o r 1 p e rs o n re s tra in in g No restraint or single-person restraint in 33% with SOC vs 81% with VR (p<0.0001)

17 Qualitative feedback: thematic analysis 1. Reduced patient pain and distress I felt the needle but was to distracted by VR to care - Child 2. Supported procedural aspects Have taken blood from this little girl before. Felt this child was much calmer than last time - Proceduralist 3. Suggestions for future Would be better if she got to watch it longer before the blood test. We were rushed at pathology and didn't get to try it beforehand - Caregiver

18 Pragmatic pilot General hospital VR used by treating clinicians Variety of procedures Streamlined clinician UX Easy operation Looping Training

19 Pragmatic pilot General hospital VR used by treating clinicians Variety of procedures Streamlined clinician UX Easy operation Looping Training 500+ uses Supported clinician workflow Improved child experience Greater family satisfaction - Introducing VR to child - Ongoing clinician training Whenever we had a difficult patient, [clinicians] did reach for the goggles and they have been wonderful - ED Area Manager

20 Conclusion In two concurrent studies, VR reduced the primary endpoint of pain and the secondary outcomes of anxiety, need for restraint Outcomes were robust in statistical analyses, and triangulated against qualitative data Adopted in pragmatic pilots in general hospital settings VR should be considered as a useful needle adjunct Chan et al. Under review

21 Acknowledgements Dr Erin Mills A/Prof Simon Craig Dr Simon Cohen Dr Paul Leong Ms Emma Ramage Prof Andrew Davidson Karin Plummer Prof Cathy Crock Dr Amanda Stock A/Prof Sandy Hopper Jenny Levy Dr Alexius Julian Roy Wallace Dr Matt Summerscales Dr Preggie Nair ED and Pathology staff, patients and families

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23 Paediatric pain: four non-negotiables 1. Topical local anaesthetic 2. (0-12 months: sucrose/breastfeeding) 3. Comfort positioning 4. Age-appropriate distraction Friedrichsdorf Ped Pain Letter 2016

24 Adverse effects: pharmacotherapy not required ED SOC N=4 Dizziness, nausea, headache, vomiting VR Nil P=0.05 Pathology SOC N=3 Nausea, vomiting, headache VR N=3 Nausea, headache P = NS

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26 Mechanism of action 1. Psychology Gate control theory 1 2. Anatomical fmri work anterior cingulate cortex 2,3 1. Melzak et al. Psychol Bulletin Gold et al. Cyberpsych & Behavior Hoffman et al. CNS Spect 2006