A review of a journal article created by a Journal Watch contributor

The effect of augmented reality on preoperative anxiety in children and adolescents

A randomized controlled trial

Pediatric Anesthesia

Submitted November 2023 by Dr Jon Stacey

Read by 158 Journal Watch subscribers

Augmented Outcomes or Virtual Benefits?

Prior to a more thorough discussion, and for those with limited time, it must first be noted that the text of the abstract and that of the manuscript’s main body are in direct contradiction (see Letter to the Editor:

Recognising the frequency and deleterious effects of perioperative anxiety and distress, Chamberland et al sought to investigate the possible benefits of augmented reality (AR) in the preoperative setting.

Their introduction provides a helpful oversight as to the key differences between augmented and virtual reality (VR).

In a single-centre prospective randomised controlled trial, the authors randomised healthy children over five years of age undergoing elective day case surgery, with a sample size based on pre-existing studies of the use of virtual reality in preoperative anxiety.

‘Standard care’ in the control group involved the child and parents being admitted first to a day surgery waiting room, and then the operating room (OR) waiting room, from whence the child (not parents) was taken to the OR by the anaesthetist. Music, video games and tablets were not allowed in the OR.

Children in the intervention arm followed the same trajectory, but were provided with augmented reality through Microsoft HoloLens2 glasses in the day surgery waiting room. Two virtual ‘avatars’ then guided the children through a variety of breathing, relaxation and motivational exercises. The longest was of 16 minutes, in the day surgery waiting room, followed by shorter exercises in both the OR waiting room and immediately prior to induction. The minimum time required to complete the intervention prior to entry to the OR was 20 minutes.

Pre-medication was used in neither group.

Pre-operative anxiety, as measured by the short form of the modified Yale Preoperative Scale (mYPAS-SF) was measured by a blinded research assistant at the time of admission (T0) and by the unblinded anaesthetist at the time of induction (T1). Patient satisfaction was also crudely measured. Analysis was per protocol, rather than by intention-to-treat.

The 37 patients who completed the augmented reality protocol had significantly lower anxiety scores at the time of induction (median difference [95%CI]: 6.3 [0-10.4], p = 0.01) than the 64 patients of the control arm.

Although the median in both groups was less than the accepted threshold (mYPAS-SF > 30), more children in the control group manifested significant anxiety at induction than in the AR group (risk ratio [95% CI]: 2.7 [1.2-5.9], p = 0.01).

Reported satisfaction in the AR group was high, with no complaints of cybersickness, despite an average wear time of 51 minutes (much longer than VR headsets have been tolerated in previous studies).

In their discussion, the authors accept that they were not able to dissociate the relative contributions of the relaxation techniques themselves and the AR technology through which these were delivered, and resource limitations around the use of headsets.

So what to make of this?
1. The control group represents standard Antipodean practice neither in terms of parental presence nor the acceptance of devices in the OR.
2. Of 64 patients randomised, 23 failed to complete the AR intervention, whether due to hardware malfunction (4), headset removal (9), or change in OR scheduling (10). Analysis by intention-to-treat would have been more revealing, without which it is hard to share the authors’ enthusiastic conclusions.
3. A number of children in both groups demonstrated significant preoperative anxiety as manifest by a mYPAS-SF score of >30. It remains incumbent on all those looking after children to consider how best to mitigate anxiety and distress at each stage of the perioperative journey. On this note, would recommend the work of the EPIC (Effective Peri-procedural Communication) group (

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