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 • Common 1 • Most feared 1,2 • Control of pain and anxiety crucial for successful procedures 3 • Suboptimally controlled 1,2,3 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 Selective concealment reporting - Gershon 2004 Port access 59 + ? Gold 2006 IV cannula 20 + ? ? Gold 2017 Venepuncture 143 + + ? - Wolitzky 2005 Port access 20 ? ? 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 PREPARE IDENTIFY, INSERT BLOOD DRAW WRAP UP Set up equipment ID and test check Tourniquet, find vein Draw blood Apply bandaid Insert needle Remove needle Label tubes INTRODUCTION RELAXATION DOLPHIN RIDE WRAP UP FISH FEEDING Start VR experience Guided relaxation Keeping still Positive reinforcement Keeping still Deep breathing Orient to VR Re-framing sensations Immersive distraction

Study design Standard of care Baseline Post procedure Screening Randomisation measures measures VR Monash Human Research Ethics Committee: HREC/17/MonH/15 Prospective registration ANZCTR: ACTRN12617000285358

Study design Standard of care Baseline Post procedure Screening Randomisation measures measures VR Inclusion criteria Exclusion criteria 4-11 years old Significantly unwell IVC or venepuncture Unable to complete measures Able to complete measures (e.g. significant disability) Informed consent / assent Monash Human Research Ethics Committee: HREC/17/MonH/15 Prospective registration ANZCTR: ACTRN12617000285358

Primary outcome: pain (FPS-R) Standard of care Baseline Post procedure Screening Randomisation measures measures 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 Pathology SOC (n= 59) VR (n= 64) SOC (n= 66) VR (n= 63) Age 8.2 7.9 Age 7.4 8.2 Sex 46% F 45% F Sex 46% F 40% F 54% M 55% M 54% M 60% M Baseline pain 4 4 Baseline pain 0 0 Topical local 85% 89% Topical local 14% 13% anaesthetic anaesthetic Procedure 20% venepunc 17% venepuc Procedure 100% venepunc 100% venepunc 80% IVC 83% IVC

VR reduces pain in ED and pathology ED Pathology 4 4 2 2 C h a n g e in p a in C h a n g e in p a in fro m b a s e lin e 0 fro m b a s e lin e 0 -2 -2 S ta n d a rd o f c a re Virtu a l re a lity S ta n d a rd o f c a re Virtu a l re a lity Mean difference: -1.78 units (p=0.018) Mean difference -1.39 units (p=0.034)

VR reduces pain in ED and pathology ED Pathology 4 4 2 2 C h a n g e in p a in C h a n g e in p a in fro m b a s e lin e 0 fro m b a s e lin e 0 -2 -2 S ta n d a rd o f c a re Virtu a l re a lity S ta n d a rd o f c a re Virtu a l re a lity Mean difference: -1.78 units (p=0.018) Mean difference -1.39 units (p=0.034) Multivariate linear regression Baseline pain, age, sex, topical local anaesthetic, prior needle exposure (p=0.03) (p=0.019)

VR reduced anxiety ED Pathology 4 4 2 2 C h a n g e in a n x ie ty C h a n g e in a n x ie ty 0 0 fro m b a s e lin e fro m b a s e lin e -2 -2 S ta n d a rd o f c a re Virtu a l re a lity S ta n d a rd o f c a re Virtu a l re a lity Mean difference: -1.56 units (p=0.016) Mean difference: -1.75 units (p=0.011)

VR reduces the need for restraint ED Pathology 1 0 0 1 0 0 7 5 7 5 % 5 0 % 5 0 2 5 2 5 0 0 S ta n d a rd o f c a re Virtu a l re a lity S ta n d a rd o f c a re Virtu a l re a lity 2 o r m o re p e o p le re s tra in in g 2 o r m o re p e o p le re s tra in in g 0 o r 1 p e rs o n re s tra in in g 0 o r 1 p e rs o n re s tra in in g No restraint or single-person restraint No restraint or single-person restraint in 33% with SOC vs 81% with VR in 51% with SOC vs 83% with VR (p<0.0001) (p=0.0002)

Qualitative feedback: thematic analysis 1. Reduced patient pain and distress “I felt the needle but was to distracted by VR to care” - Child 2. Supported procedural aspects “Have taken blood from this little girl before. Felt this child was much calmer than last time” - Proceduralist 3. Suggestions for future “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 500+ uses • VR used by treating clinicians  Supported clinician workflow • Variety of procedures  Improved child experience  Streamlined clinician UX  Greater family satisfaction  Easy operation - Introducing VR to child  Looping - Ongoing clinician training  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 VR should be considered as a useful needle adjunct Chan et al. Under review

Acknowledgements • Jenny Levy • Dr Erin Mills • Prof Andrew Davidson • Dr Alexius Julian • A/Prof Simon Craig • Karin Plummer • Roy Wallace • Dr Simon Cohen • Prof Cathy Crock • Dr Matt Summerscales • Dr Paul Leong • Dr Amanda Stock • Dr Preggie Nair • Ms Emma Ramage • A/Prof Sandy Hopper ED and Pathology staff, patients and families

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 Pathology • SOC • SOC • N=4 • N=3 • Dizziness, nausea, headache, • Nausea, vomiting, headache vomiting • VR • VR • N=3 • Nil • Nausea, headache • P = NS P=0.05

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