needle procedural pain Dr Evelyn Chan Needle pain is common and - - PowerPoint PPT Presentation

Virtual reality for paediatric needle procedural pain

Dr Evelyn Chan

Needle pain is common and undermanaged

• Needles
• Common1
• Most feared1,2
• Control of pain and anxiety

crucial for successful procedures3

• Suboptimally controlled1,2,3
• 1. Friedrichsdorf et al. Hosp Pediatrics 2015
• 2. Shomaker et al. Hosp Pediatrics 2015
• 3. Krauss et al. Lancet 2016

Virtual reality (VR)

Literature is generally at high risk of bias

Study Procedure n =

Randomisation Allocation concealment Selective reporting

Gershon 2004 Port access 59 Gold 2006 IV cannula 20 Gold 2017 Venepuncture 143 Wolitzky 2005 Port access 20

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• Chan et al. PLoSONE 2018

Meta-analysis suggests needle pain benefit

Chan et al. PLoSONE 2018

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: ACTRN12617000285358 Chan et al. Under review

VR development

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

Study design

Screening Baseline measures Randomisation Post procedure measures

Standard of care VR

Monash Human Research Ethics Committee: HREC/17/MonH/15 Prospective registration ANZCTR: ACTRN12617000285358

Study design

Screening Baseline measures Randomisation Post procedure measures

Standard of care VR

Monash Human Research Ethics Committee: HREC/17/MonH/15 Prospective registration ANZCTR: ACTRN12617000285358 Inclusion criteria Exclusion criteria 4-11 years old IVC or venepuncture Able to complete measures Informed consent / assent Significantly unwell Unable to complete measures (e.g. significant disability)

Primary outcome: pain (FPS-R)

Screening Baseline measures Randomisation Post procedure measures

Standard of care VR

Monash Human Research Ethics Committee: HREC/17/MonH/15 Prospective registration ANZCTR: ACTRN12617000285358 Hicks et al. Pain 2001

Group were balanced at baseline

ED

SOC (n= 59) VR (n= 64) Age 8.2 7.9 Sex 46% F 54% M 45% F 55% M Baseline pain 4 4 Topical local anaesthetic 85% 89% Procedure 20% venepunc 80% IVC 17% venepuc 83% IVC

Pathology

SOC (n= 66) VR (n= 63) Age 7.4 8.2 Sex 46% F 54% M 40% F 60% M Baseline pain Topical local anaesthetic 14% 13% Procedure 100% venepunc 100% venepunc

VR reduces pain in ED and pathology

ED Pathology

Mean difference: -1.78 units (p=0.018) Mean difference -1.39 units (p=0.034)

S ta n d a rd o f c a re Virtu a l re a lity

• 2

2 4

C h a n g e in p a in fro m b a s e lin e

S ta n d a rd o f c a re Virtu a l re a lity

• 2

2 4

C h a n g e in p a in fro m b a s e lin e

VR reduces pain in ED and pathology

ED Pathology

Mean difference: -1.78 units (p=0.018) Mean difference -1.39 units (p=0.034)

S ta n d a rd o f c a re Virtu a l re a lity

• 2

2 4

C h a n g e in p a in fro m b a s e lin e

S ta n d a rd o f c a re Virtu a l re a lity

• 2

2 4

C h a n g e in p a in fro m b a s e lin e

Multivariate linear regression Baseline pain, age, sex, topical local anaesthetic, prior needle exposure (p=0.03) (p=0.019)

VR reduced anxiety

S ta n d a rd o f c a re Virtu a l re a lity

• 2

2 4

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 rd o f c a re Virtu a l re a lity

• 2

2 4

C h a n g e in a n x ie ty fro m b a s e lin e

Mean difference: -1.75 units (p=0.011) Mean difference: -1.56 units (p=0.016)

ED Pathology

VR reduces the need for restraint

ED Pathology

S ta n d a rd o f c a re Virtu a l re a lity 2 5 5 0 7 5 1 0 0

% 0 o r 1 p e rs o n re s tra in in g 2 o r m o re p e o p le re s tra in in g

S ta n d a rd o f c a re Virtu a l re a lity 2 5 5 0 7 5 1 0 0

% 0 o r 1 p e rs o n re s tra in in g 2 o r m o re p e o p le re s tra in in g

No restraint or single-person restraint in 51% with SOC vs 83% with VR (p=0.0002) No restraint or single-person restraint in 33% with SOC vs 81% with VR (p<0.0001)

Qualitative feedback: thematic analysis

• 1. Reduced patient pain and distress
• 2. Supported procedural aspects
• 3. Suggestions for future

“I felt the needle but was to distracted by VR to care” - Child “Have taken blood from this little girl before. Felt this child was much calmer than last time” - Proceduralist “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

Pragmatic pilot

• General hospital
• VR used by treating clinicians
• Variety of procedures

Streamlined clinician UX

Easy operation Looping

Training

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

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

Chan et al. Under review

VR should be considered as a useful needle adjunct

Acknowledgements

• Prof Andrew Davidson
• Karin Plummer
• Prof Cathy Crock
• Dr Amanda Stock
• A/Prof Sandy Hopper
• Dr Erin Mills
• A/Prof Simon Craig
• Dr Simon Cohen
• Dr Paul Leong
• Ms Emma Ramage

ED and Pathology staff, patients and families

• Jenny Levy
• Dr Alexius Julian
• Roy Wallace
• Dr Matt Summerscales
• Dr Preggie Nair

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

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

Mechanism of action

• 1. Psychology
• “Gate control theory”1
• 2. Anatomical
• fMRI work – anterior cingulate cortex2,3
• 1. Melzak et al. Psychol Bulletin 1965
• 2. Gold et al. Cyberpsych & Behavior 2007
• 3. Hoffman et al. CNS Spect 2006