Virtual reality distraction decreases routine intravenous sedation and procedure-related pain during preoperative adductor canal catheter insertion
Background: Ultrasound has decreased pain related to perineural catheter insertion, but it is still common to administer routine intravenous sedation. Virtual reality (VR) distraction has been used as a nonpharmacologic method to prevent acute pain related to burn dressing changes and other minor procedures but has not been previously studied in conjunction with anesthesiology procedures. We employed VR distraction as a quality improvement project to eliminate routine intravenous sedation for patients undergoing preoperative adductor canal catheter (ACC) placement prior to elective total knee arthroplasty (TKA) and present our experience.
Methods: This retrospective cohort study was approved by the local VA research committee and our Institutional Review Board with a waiver on informed consent. For the first half of one month, all patients who presented for elective unilateral primary TKA with a preoperative ACC received usual care; intravenous sedation was offered and administered at the discretion of the regional anesthesiologist and titrated to patient comfort. For the second half of the month, patients were offered VR distraction (Figures 1 and 2) and were told that intravenous sedation was immediately available and would be administered upon request. Selection of patients to receive VR for this project was not random and was dependent on the availability of the VR distraction device and a practitioner to coach patients on its use. The primary outcome was fentanyl dosage (mcg). Secondary outcomes were midazolam dosage (mg), procedure-related pain (numeric rating scale 0-10), procedural time (minutes), and blood pressure change scores (mmHg).
Results: Fourteen patients underwent elective unilateral primary TKA and received a preoperative ACC during the project period; 7 patients received usual care without VR, and 7 patients were offered and chose to try VR. Baseline characteristics between groups were similar except for height. In the VR group, only one patient received intravenous sedation compared to 6 out of 7 who received usual care (p = 0.029). The primary outcome, fentanyl dose, was lower [median (10th-90th percentiles)] in the VR group [0 (0-20) mcg] compared to the non-VR group [50 (30-100) mcg; p = 0.008]. Midazolam use was lower in the VR group [0 (0-0) mg] compared to non-VR [1 (0-1) mg; p = 0.024]. Procedure-related pain was lower in the VR group [1 (1-4)] versus the non-VR group [3 (2-6); p = 0.032]. There were no differences in other outcomes. No patients who received VR reported dizziness or experienced nausea, vomiting, or other undesirable effects.
Conclusions: The use of VR distraction during ACC insertion decreases use of intravenous opioids and sedatives and reduces procedure-related pain without increasing the procedural duration. Our data suggest that VR distraction may provide an effective nonpharmacologic alternative to intravenous sedation for ultrasound-guided placement of certain perineural catheters.