232 A Randomized Controlled Trial on Virtual Reality Use as a Distraction Technique for Orthopedic Injuries Requiring Sedation

Abstract

Pain is a common medical complaint, and one that is exacerbated by several procedures in the emergency department (ED) including intravenous (IV) line placement and manipulative procedures (radiographic imaging, casting). Inadequate pain control during these procedures can intensify pediatric anxiety, potentially resulting in complications or need for escalation of care. Distraction techniques have been utilized to reduce pain and anxiety with varying success depending on the modality used. Recently, more immersive distraction techniques, namely virtual reality (VR), have shown a reduction in sedation needed in burn patients, as well as reduced anxiety around port access in pediatric cancer patients. The use of VR in the pediatric ED for sedation in orthopedic injuries requiring reduction and/or casting has not yet been fully explored. This study aims to assess anxiety, pain, and patient satisfaction while observing medication requirements during orthopedic fracture reduction procedures in the ED with and without the supplemental use of VR technology. The primary objective was to assess differences in anxiety levels between children that used a VR experience and those treated without VR during an orthopedic fracture reduction procedure. Secondary objectives included pain scores pre- and post-procedure, necessity of sedation redosing, and physician satisfaction with orthopedic procedure. This was a randomized control trial at a Pediatric Emergency Department and Level 1 Trauma Center located in the Southern United States. All pediatric orthopedic patients over five years old who required sedation for casting and/or reduction of their injury were asked to enroll (N= 115). Of those, 104 consented to participate (90%). After enrollment, using an online random generator, patients were randomized to one of two groups: VR experience or non-VR experience. The FACES scale and mYPAS were completed by a child life specialist to assess pain and anxiety, respectively. All data was collected prospectively and medical records were accessed only to validate data. A total of 104 pediatric patients were included in this study (n= 52 in each group). Average age of participants was 9.5 years old, and most were White or Hispanic, 55 (53%) and 22 (21%), respectively. There were no significant differences in age, race or ethnicity. Patients in the VR group (22.92 [IQR: 22.92 – 36.45]) were significantly less anxious than children in the non-VR group (35.42 [IQR: 22.92 – 50.00]), p =.001. Furthermore, because the use of midazolam as an anxiolytic is rather common during procedures, a sub-analysis of patients who did not need receive midazolam was conducted. Among children that did not receive midazolam, anxiety levels were also statistically significant, (p = .002). The number of sedative doses, pain scores, and the need for opioid use post procedure were similar between groups (ps >.05). Similarly, there were no significant difference in physician satisfaction, reduction time, need for open reduction, or pre-procedure opioid use. The use of a virtual reality experience is a successful distraction technique which can decrease pediatric anxiety levels during procedural sedation in the emergency department. This is an easy tool to incorporate into daily clinical practice and can improve patient outcomes.