3-Dimensional Virtual Reality Versus 2-Dimensional Video for Distraction During the Induction of Anesthesia in Children to Reduce Anxiety
A Randomized Controlled Trial
Anesthesia Analgesia
Submitted January 2026 by Dr Tim Durack
Read by 21 Journal Watch subscribers
Summary
This study did not find 3D virtual reality (VR) to be superior to 2D tablet audiovisual distraction in reducing anxiety during induction for children undergoing emergency or elective surgery.
Methods
- Single-centre tertiary paediatric hospital, randomized, controlled, parallel-group trial
- 200 children (4-13 years) recruited from day-of-surgery admissions ward undergoing a broad range of elective or emergency surgery
- Randomly allocated to VR or tablet to watch a 5-minute underwater-themed video with breathing exercises in the anaesthetic room with 1 parent or carer
- Induction method at discretion of anaesthetist
- The only premedication permitted was clonidine (only 7 patients received this)
Primary outcome:
- Pre-operative anxiety at check-in and at induction (mYPAS-SF)
Secondary outcomes:
- Pre-operative “state” and “trait” anxiety (STAI-C)
- Induction compliance (Induction Compliance Checklist)
- Emergence delirium (CAP-D)
- Usefulness judged by anaesthetist, anaesthetic technician and parent (Likert scale)
- Child satisfaction (Likert-like faces)
Children were not selected on the basis of baseline anxiety, and only about one quarter to one third were classified as having “high anxiety” by the measures listed above
Findings
- No significant difference between VR and 2D tablet distraction on induction anxiety
- Much larger and more consistent associations with reduced anxiety were age (9+), better child-reported tolerance of past procedures, and inhalation induction (unless inhalation selected for child 9+ years old)
- There were generally high usefulness and satisfaction ratings perceived by staff, parents and children for both VR and 2D distraction, and no difference detected in emergence delirium
- The few minor differences within the secondary outcomes at or near threshold statistical significance should be interpreted with extra caution, as these ordinal, skewed rating scales were analysed as continuous data with normally distributed residuals
Context
Previous studies in children have found:
- Higher perioperative anxiety is associated with emergence delirium
- Portable tech devices can reduce anxiety at induction
- Use of VR during medical procedures is associated with reduced peri-procedural anxiety
- With prior evidence that digital distraction can reduce procedural anxiety, this study chose not to include a control group without digital distraction. It assesses relative, rather than absolute benefit of VR vs tablet distraction
Strengths
- Novel head-to-head comparison of VR vs tablet during induction using established assessment tools where available
- Specific to induction, rather than a range of awake procedures such as IV access, burns dressing changes, oncology procedures etc.
Several aspects reflected real practice particularly well:
- Intention-to-treat analysis allowed for inclusion of the small number of children who experienced real-life technical issues with either device
- Patients were not introduced to the devices until just before induction
- Patients underwent a broad range of both elective and emergency surgeries, though it is not reported what proportion were elective vs emergency
- Clinically realistic exclusion criteria
- Induction method left to discretion of anaesthetist
- Comments were collected from staff, which identified issues with mask seal next to the VR device, and difficulty assessing depth of anaesthesia with eyes covered by the device
Limitations/caveats
- The statistics used are better suited to identifying the direction of effects, rather than the magnitude of the small effects seen in the study
- It’s not clear how many IV inductions included cannulation vs use of a pre-existing line, as can be the case in patients having emergency procedures. It would be reasonable to expect greater need for distraction during inductions involving cannulation
- Both a strength and a limitation is that the distraction video was the same for everyone. This did not assess whether a more interactive program such as a game might be more effective in VR vs tablet format. It is common practice to allow children to choose their distraction on a tablet, and this was not available for either VR or tablet
- Not designed to find a subset of patients who might benefit more from VR vs tablet, for instance older children receiving an IV induction
- It would have been interesting to collect the free-text experiences of parents and older children. This may have revealed practical tips for digital distraction, as did the comments from staff
- It is reasonably left to the reader to decide whether they value more very high scores or fewer very low scores in evaluating the usefulness and satisfaction ratings
- Given the cost, training, and workflow implications of VR, a department might reasonably ask whether its use could be targeted to highly anxious children. This study does not answer that question. In the high-anxiety subgroup, the sample was underpowered to detect anything but a large effect, and the observed data suggest no meaningful difference between VR and tablet distraction
Final thoughts
When a standardized video is used at induction, VR does not reduce children’s anxiety or increase satisfaction significantly compared to a tablet. It is interesting to wonder why. In simulation education, physical fidelity alone rarely determines immersion and effectiveness; psychological engagement and task relevance matter more.
What are the equivalent factors for induction anxiety? This study identifies multiple factors far more strongly associated with induction anxiety than distraction modality: age, mode of induction, and prior tolerance of procedures. Only one of these is modifiable in the induction bay. This is likely an incomplete list, as other contributors—such as parental anxiety—are well described elsewhere but were outside the scope of this study.
Several questions about VR’s use for reducing induction anxiety remain:
- Are there specific subgroups—such as older children undergoing IV induction or those exposed repeatedly to anaesthesia—who may benefit more from VR?
- Is a more interactive VR app chosen by the child more effective than a similar tablet app?
