Effect of immersive virtual reality in reducing anxiety and improving success during paediatric computed tomography imaging – An observational study

Diagnostic tests often provoke fear and anxiety in pediatric patients, leading to the need for sedation or general anaesthesia (GA). Virtual reality has been used as a distraction tool in children during various minor procedures, circumventing the need for sedation. However, its use as an alternative to pharmacological anxiolysis during CT scan has never been explored. This single arm feasibility study aims to assess the feasibility of VR in decreasing anxiety among the pediatric patients undergoing CT scans. The primary objective is to determine the percentage of pre-school and school-aged children (3 to 8 years) who complete CT imaging under virtual reality without supplementary intravenous sedation. The secondary objectives are1. To evaluate the affect and cooperation of children during CT scan under virtual reality2. To determine the mean dose of intravenous sedatives required to successfully complete CT imaging3. To determine the number of interruptions during the scanning procedure 4. To determine the satisfaction scores by the attending radiologist.

The Inclusion criteria are:1. Preschool and school aged children between 3 to 8 years 2. Children scheduled for CT imaging under sedation 3. ASA physical status I/II/IIIThe Exclusion criteria are: 1. CT scan of head, paranasal sinuses, orbit 2. Children with mental, auditory or visual impairment 3. Anticipated difficult airway 4. Unstable patient or urgent procedure 5. Allergy to EMLA cream or any of the intravenous sedatives used 6. Parent/guardian refusal 7. Child refusal. Parents will be explained in their language that their child will be participating in a study and written consent/assent will be obtained. Consecutive eligible patients over the duration of 1 year will be recruited.

Only uncooperative patients scheduled for the scan under sedation will be enrolled for the study. For the eligible patients, a modified Yale preoperative anxiety scale will be used to assess baseline anxiety in the holding area. In the preprocedural room EMLA cream will be applied. The patients will then be made to wear the VR headset while on the trolley. After 45 minutes, the site of EMLA application will be uncovered and intravenous cannulation will be attempted in the presence of the parents. The response to IV catheter placement will be graded using the Groningen Distress Rating Scale (GDRS). The number of attempts to successful cannula placement will be recorded. The parent’s satisfaction will be recorded.

After cannulation, children will be wheeled to the CT scanner for imaging. Pre-procedure anxiety score will again be noted and the procedure will be commenced. Patients will continue to watch the video before and until completion of the scanning. Patient cooperation will be assessed using a 5-point scale: 1 = cooperative; 2 = verbal resistance; 3 =some movement, intermittent restraint required; 4 = thrashing movements, continuous restraint required; and 5 =unable to complete procedure without intravenous medication. In cases where there is difficulty in completing the procedure because of the child’s anxiety or inability to remain still,  ketamine 0.5 mg/kg IV will be given as an initial dose, followed by subsequent doses of 0.5 mg/kg propofol IV if required. Oxygen supplementation via nasal prongs @2ltr/min will be provided and standard ASA monitoring will be employed. The total dose of intravenous agents required will be noted. Any movement, motion artifact or repeat scans reported by radiologist will be recorded. Any complications like desaturation, airway obstruction, vomiting or excessive salivation will also be noted.

Post procedure, the investigator will grade the affect of children as happy, relaxed, anxious or distressed, and their cooperativity using the HRAD+ scale. The radiographer/radiologistsatisfaction with the procedure will be measured using a 5-point Likert scale, ranging from 1 ‘very dissatisfied’ to 5 ‘very satisfied. VR feasibility and technical issues will be recorded throughout the study period.

Recovery time defined as the time from the end of sedation (if required) to physiologic recovery state allowing safe discharge from the CT suite. The patients will be shifted to the recovery area and observed for an hour after the scan. The children will be discharged when their vital signs are stable and consciousness has returned to an age-appropriate baseline.