Effects of immersive virtual reality therapy on intravenous patient-controlled sedation during orthopaedic surgery under regional anesthesia: A randomized controlled trial.

BACKGROUND: Immersive virtual reality (IVR) is a form of distraction therapy that has shown potential as an analgesia and sedation sparing agent. This study assessed the effect of IVR on the self-administered sedation requirements of patients undergoing joint replacement surgery under regional anesthesia in a single center. METHODS AND FINDINGS: This study was a single-center, randomized control trial at St Vincent's Hospital in Melbourne, Australia. Fifty patients undergoing elective total knee and total hip arthroplasty were randomized to IVR and Propofol patient-controlled sedation (PCS) or propofol PCS alone. The primary outcome measure was intra-operative propofol use. Secondary outcomes included pattern of propofol use over time, use of adjunct analgesia, unmet propofol demand, and patient satisfaction survey scores. Of 50 total patients, 25 received IVR in conjunction with PCS, and 25 received PCS alone. All patients received adjunct analgesia from the treating Anesthesiologist. Median propofol use/hour over the entire procedure in the control group was 40 (11.1, 93.9) mg/hour compared with 45 (0, 94.7) mg/hour in the IVR group (p = 0.90). There were no differences in patterns of propofol use over the course of each procedure. Adjusting for various baseline characteristics did not change the results. Postoperative satisfaction scores were equivalent in both groups. The VR intervention was well tolerated by all patients, with no report of major side effects. Key limitations were relatively small sample size, the non-blinded nature of the study, and use of adjunct analgesia. CONCLUSIONS: In patients receiving joint replacement surgery under regional anesthesia with PCS, IVR was well tolerated but did not decrease the overall sedation requirement.

Virtual Reality as an Adjunctive Nonpharmacological Sedative During Orthopedic Surgery Under Regional Anesthesia: A Pilot and Feasibility Study.

This pilot study assessed the feasibility and potential for any possible sedation sparing effect of immersive virtual reality (IVR) therapy on patients undergoing joint replacement surgery under regional anesthesia. Nine participants were given IVR, regional anesthetic, and sedation. Ten received conventional care. Mean propofol usage was 155 ± 45 mg/h in the conventional care group and 63 ± 21 mg/h in the IVR group (P = .088, mean difference -91.6 mg/h, 95% confidence interval, -200 to 16.87 mg/h). There was no significant difference in postoperative satisfaction between the 2 groups. This pilot study demonstrates that it is possible to safely provide IVR in an operating theater environment and may confer a sedation sparing effect. A larger, more powered, and randomized study is needed to assess this effect.

Understanding post-hospital morbidity associated with immobilisation of cervical spine fractures in older people using geriatric medicine assessment techniques: A pilot study.

INTRODUCTION: There is a paucity of research into the outcomes and complications of cervical spine immobilisation (hard collar or halothoracic brace) in older people. AIMS: To identify morbidity and mortality outcomes using geriatric medicine assessment techniques following cervical immobilisation in older people with isolated cervical spine fractures. PATIENTS AND METHODS: We identified participants using an injury database. We completed a questionnaire measuring pre-admission medical co-morbidities and functional independence. We recorded the surgical plan and all complications. A further questionnaire was completed three months later recording complications and functional independence. RESULTS: Sixteen patients were recruited over a three month period. Eight were immobilised with halothoracic brace, 8 with external hard collar. Three deaths occurred during the study. Lower respiratory tract infection was the most common complication (7/16) followed by delirium (6/16). Most patients were unable to return home following the acute admission, requiring sub-acute care on discharge. The majority of patients were from home prior to a fall, 6/16 were residing there at 3 months. Most participants had an increase in their care needs at 3 months. There was no difference in the type or incidence of complications between the different modes of immobilisation. CONCLUSIONS: Geriatric medicine assessment techniques identified the morbidity and functional impairment associated with cervical spine immobilisation. This often results in a prolonged length of stay in supported care. This small pilot study recommends a larger study over a longer period using geriatric medicine assessment techniques to better define the issues.

Improving general practice consultations for older people with asthma: a cluster randomised control trial.

OBJECTIVE: To evaluate the effectiveness of a multifaceted educational intervention for general practitioners to improve the outcomes of older people with asthma. DESIGN: Cluster randomised controlled trial. PARTICIPANTS AND SETTING: 42 GPs recruited from metropolitan Melbourne between 1 August 2006 and 31 July 2007, randomly assigned to an intervention or control group, and 107 patients with asthma, aged 55 years or older (consecutive patients recruited by the GPs). MAIN OUTCOME MEASURES: Evaluation by means of a videorecorded consultation with a simulated patient for GPs; and for patients, asthma control and quality of life, lung function and action plan ownership at baseline and at 4 months. RESULTS: GPs in the intervention group scored significantly higher than those in the control group for the content and style of their consultation with simulated patients. At 4 months' follow-up, there was no significant difference between patient groups in the asthma control scores, asthma-related quality of life or lung function. CONCLUSION: This trial showed an improvement in GPs' performance in delivering asthma care to older people. Despite this, there was no significant improvement in patient outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12607000634471.

'You have to learn to live with it': a qualitative and quantitative study of older people with asthma.

INTRODUCTION: Asthma mortality has declined overall because of a range of public health initiatives. In western countries, the majority of asthma deaths now occur in people over the age of 50. The reasons for the poorer response of older age groups to public health asthma initiatives are not known. OBJECTIVES: We undertook a study to investigate the disease perspectives of older people with asthma and barriers which may exist and prevent optimal asthma care. METHODS: Fifty-five participants (16 male and 39 female) aged over 50 from an inner city, suburban area and a rural region were recruited. Lung function was measured, and questionnaire data on asthma symptoms, knowledge and control, medication use and respiratory health were collected. Participants were also interviewed in-depth, and the quantitative and qualitative data were triangulated. RESULTS: Participants with a duration of asthma for >30 years reported significantly fewer symptoms and better quality of life irrespective of asthma severity, indicating less appreciation of symptoms in those with a long asthma duration. Interviews revealed this was related to previous asthma management strategies when treatment options were limited. Participants with a recent diagnosis sought understanding of asthma and the reason for their illness. Initiatives to improve asthma care in older people need to reflect these findings. CONCLUSIONS: Self-management strategies for older people need to be tailored according to the time of disease onset and the duration of disease.