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

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


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

Objective: 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).

Design: A randomised controlled single-blind trial.

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

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

Intervention: 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.

Main outcome measures: 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.

Results: 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]; P = 0.862). 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%) (P = 0.002).

Conclusion: 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.

Trial registration: Netherlands Trial Registry: NTR6116.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Ambulatory Surgical Procedures / methods*
  • Analgesia
  • Anesthesia, General / methods
  • Anxiety / therapy*
  • Child
  • Child, Preschool
  • Elective Surgical Procedures / methods*
  • Emergence Delirium
  • Female
  • Humans
  • Male
  • Netherlands
  • Pain Management / methods*
  • Pain, Postoperative / therapy*
  • Preoperative Period
  • Treatment Outcome
  • Virtual Reality Exposure Therapy*