BACKGROUND: Pediatric patients undergoing general anesthesia often face stress responses, anesthetic challenges, and delayed recovery. Virtual reality has emerged as a promising non-pharmacological intervention, though its effectiveness varies across studies. This meta-analysis evaluates the effects of preoperative virtual reality interventions on various outcomes in pediatric patients.
METHODS: PubMed, EMBASE, the Cochrane Library, and Web of Science were searched for randomized controlled trials with intention-to-treat analysis comparing preoperative virtual reality interventions with standard care in pediatric patients undergoing general anesthesia. Primary outcomes included preoperative anxiety (Modified Yale Preoperative Anxiety Scale, change in Modified Yale Preoperative Anxiety Scale) and compliance during anesthesia induction (Induction Compliance Checklist). Secondary outcomes included preoperative fear (Children's Fear Scale), procedural behavior (Procedural Behavior Rating Scale), postoperative pain (Face, Legs, Activity, Cry, Consolability scale, Wong-Baker FACES Pain Rating Scale), postoperative delirium (Pediatric Anesthesia Emergence Delirium scale), and parental satisfaction. Data were analyzed using Review Manager 5.4.1, with results presented as weighted mean differences and odds ratios with 95% confidence intervals. Certainty of evidence (Grading of Recommendations, Assessment, Development and Evaluation) were also assessed.
RESULTS: Twelve RCTs were included. Compared to the control group, the virtual reality group had lower Modified Yale Preoperative Anxiety Scale scores (weighted mean difference: -12.69, 95% confidence interval: -16.17 to -9.20, p < 0.001, low evidence), greater change in Modified Yale Preoperative Anxiety Scale scores (weighted mean difference: -9.54, 95% confidence interval: -12.98 to -6.10, p < 0.001, low evidence), lower Induction Compliance Checklist scores (weighted mean difference: -1.67, 95% confidence interval: -2.02 to -1.32, p < 0.001, low evidence), lower Children's Fear Scale scores (weighted mean difference: -2.30, 95% confidence interval: -2.54 to -2.07, p < 0.001, moderate evidence), lower Procedural Behavior Rating Scale scores (weighted mean difference: -1.00, 95% confidence interval: -1.12 to -0.88, p < 0.001, moderate evidence), lower Face, Legs, Activity, Cry, Consolability scale scores (weighted mean difference: -0.26, 95% confidence interval: -0.35 to -0.18, p < 0.001, moderate evidence), lower Wong-Baker FACES Pain Rating Scale scores (weighted mean difference: -0.44, 95% confidence interval: -0.61 to -0.28, p < 0.001, moderate evidence), and higher parental satisfaction scores (weighted mean difference: 0.68, 95% confidence interval: 0.59 to 0.77, p < 0.001, moderate evidence). For categorical Induction Compliance Checklist, the virtual reality group showed significantly more perfect scores (odds ratio: 3.53, 95% confidence interval: 2.04 to 6.09, p < 0.001, moderate evidence) and fewer moderate and poor scores (odds ratio: 0.28, 95% confidence interval: 0.16 to 0.49, p < 0.001, moderate evidence). There was no statistically significant difference in emergence delirium (odds ratio: 1.05, 95% confidence interval: 0.59 to 1.89, p = 0.86, low evidence).
CONCLUSION: Based on low to moderate quality evidence, preoperative virtual reality significantly improves compliance during anesthesia induction and offers possibly clinically significant improvements in preoperative anxiety, fear, procedural behavior, and parental satisfaction in pediatric patients undergoing general anesthesia. However, virtual reality shows a very low likelihood of clinical effect on postoperative pain, based on its very small effect size, and clearly no clinical effect on emergence delirium.
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