Introduction
Sedative and narcotic medications used during colonoscopy can cause nausea/vomiting,
absence from work, impaired cognitive function and need for an escort home. These
factors are often cited as reasons patients delay or avoid colonoscopy [1]. Unsedated colonoscopy is not widely accepted [2] and inferior in quality to sedated exams [3]. This highlights the need for non-pharmacological anxiolysis and analgesia during
colonoscopy.
In previous studies, virtual reality (VR) significantly reduced pain perception in
medical settings including burn wound care (P < 0.0001) [4] and dental procedures (P = 0.000) [5]. We sought to determine whether VR may be an acceptable alternative to pharmacological
sedation during colonoscopy.
Patients and methods
Patient selection
Over a 9-month period, all individuals scheduled for screening/surveillance colonoscopy
who had previously undergone ≥ 1 colonoscopy under conscious sedation and were patients
of any of four endoscopists at our institution were invited to participate. First-time
colonoscopy patients and those who had prior colonoscopies under anesthesia or without
sedation were excluded to specifically compare VR to conscious sedation. Patients
with contraindications to conscious sedation were excluded so that all subjects had
the option of pharmacological rescue.
VR delivery
Subjects were oriented to the VR device prior to their procedure. We used the Samsung
(Ridgefield Park, New Jersey, United States) Gear VR Oculus headset fitted with a
Samsung Galaxy S7 phone. Subjects could opt out and request standard pain medications
at any time before or during their procedure.
In addition to study consent, all subjects signed a standard consent for colonoscopy
with medications. Virtual experiences were initiated just prior to colonoscope insertion
and continuously delivered throughout the procedure. Subjects were repositioned as
needed at the discretion of the performing endoscopist. In these situations, the care
team communicated over the audio component of the VR rather than interrupt. Patients
experienced multiple 1- to 7-minute audiovisual experiences featuring nature and animal
scenes. All were passive VR that did not require the viewer to move or direct travel
through the virtual environment and were considered by the investigators to be relaxing
and engaging.
Statistical analysis
Data were compared with the Mann-Whitney and Fisher tests. Relationship strength between
continuous data sets was assessed using the Pearson r correlation. Variables are presented as mean ±standard deviation. The study was IRB-approved
and registered with ClinicalTrials.gov (NCT04349150).
Results
Cohort characteristics
Twenty-seven individuals (13 male, mean age 63.9 ± 8.4 years) initiated their colonoscopy
with the VR device ([Table 1]). The cecum was intubated in all cases. Eleven subjects (40.7 %) had a history of
abdominal or pelvic surgery, and one had a tortuous colon noted on prior colonoscopy.
No other conditions that might impact the exam were noted. 22 (81.5 %) had one or
more prior colonoscopies performed by the same endoscopist who did the study exam.
Five (18.5 %) had their prior procedures performed by a different endoscopist at our
institution. Mean drug doses administered during prior colonoscopies were 3.7 ± 1.2 mg
midazolam/70.6 ± 21.2 mg meperidine and 4.2 ± 1.1 mg midazolam/103.9 ± 44.3 µg fentanyl.
Table 1
Baseline characteristics of study cohort
|
Number
|
27
|
|
Sex (M:F)
|
13:14
|
|
Mean age, y ±SD
|
63.9 ± 8.4
|
|
Mean BMI, kg/m2 ± SD
|
26.2 ±3.8
|
|
No. of prior colonoscopies – n (%)
|
1 colonoscopy – 8 (29.6)
2 colonoscopies – 10 (37.0)
≥ 3 colonoscopies – 9 (33.3)
|
|
Medical history potentially impacting exam difficulty – n (%)
|
Abdominal/pelvic surgery – 11 (40.7)
Tortuous colon – 1 (3.7)
None – 15 (55.6)
|
|
At least 1 prior colonoscopy performed by study endoscopist
|
Yes – 22 (81.5)
No – 5 (18.5)
|
|
Mean medication doses (meperidine) in prior colonoscopies, ± SD
|
3.7 ± 1.2 mg midazolam
70.6 ± 21.2 mg meperidine
|
|
Mean medication doses (fentanyl) in prior colonoscopies, ± SD
|
4.2 ± 1.1 mg midazolam
103.9 ± 44.3 µg fentanyl
|
SD, standard deviation; BMI, body mass index
Colonoscopies completed with VR and no pharmacological rescue
Of the participants, 96.3 % (26/27) completed their colonoscopy without requesting
or receiving any sedative or narcotic medication. These 26 subjects rated their pre-procedure
anxiety at a mean of 3.8 ± 2.2/10, procedural pain at 3.6 ± 1.6/10, and discomfort
at 4.0 ± 1.4/10 (1 = no anxiety/pain/discomfort, 10 = extreme anxiety/pain/discomfort).
Subjects compared their feelings to those experienced at their prior colonoscopy.
The results are described in [Table 2]. Overall, pre-procedure anxiety was weakly correlated with pain (r = 0.33) and discomfort (r = 0.44).
Table 2
Patient experience and study data on colonoscopy
|
Patient experience with virtual reality
|
No medication requested during colonoscopy (n = 26)
|
Medication requested during colonoscopy (n = 1)
|
|
Pre-procedure anxiety; mean ± SD[1]
|
3.8 ± 2.2
|
3
|
|
Anxiety compared to first colonoscopy – n (%)
|
Less anxiety – 11 (42.3)
Similar anxiety – 8 (30.8)
More anxiety – 3 (11.5)
Anxious about study, not about procedure – 3 (11.5)
Do not remember – 1 (3.8)
|
More anxiety – 1 (100)
|
|
Procedural pain; mean ± SD[1]
|
3.6 ± 1.6
|
2
|
|
Pain compared to prior colonoscopies – n (%)
|
Less pain – 1 (3.8)
Similar pain – 11 (42.3)
More pain – 11 (42.3)
No response – 3 (11.5)
|
More pain – 1 (100)
|
|
Procedural discomfort; mean ± SD[1]
|
4.0 ± 1.4
|
4
|
|
Discomfort compared to prior colonoscopies – n (%)
|
Less discomfort – 1 (3.8)
Similar discomfort – 11 (42.3)
More discomfort – 13 (50.0)
No response – 1 (3.8)
|
More discomfort – 1 (100)
|
|
How satisfied are you with your overall experience? Mean ± SD[2]
|
7.3 ± 2.5
|
3
|
|
Would you choose VR instead of pain medication for colonoscopy again? – n (%)
|
Yes – 18 (69.2)
Maybe – 7 (26.9)
No – 1 (3.8)
|
No – 1 (100.0)
|
|
How likely are you to recommend VR during colonoscopy to a friend or family member?
Mean ± SD, scale 1–10[3]
|
7.4 ± 2.4
|
1
|
|
Colonoscopy characteristics
|
|
Mean duration of colonoscopy, minutes ± SD
|
22.6 ± 8.9
|
19.0
|
|
Diverticula noted, n (%)
|
13 (50.0)
|
1 (100.0)
|
|
Polyps removed, n (%)
|
11 (42.3)
|
1 (100.0)
|
|
Mean number of polyps per subject with polyps ± SD
|
2.1 ± 1.8
|
1
|
|
Mean polyp size, mm ± SD
|
4.9 ± 3.8
|
1.0
|
SD, standard deviation; VR, virtual reality
1 Scale of 1–10 (1 = no anxiety/pain/discomfort, 10 = extreme anxiety/pain/discomfort).
2 Scale of 1–10 (1 = not satisfied, 10 = extremely satisfied)
3 Scale of 1–10 (1 = not likely, 10 = extremely likely)
Six of 26 patients (23.1 %) considered asking for medication at some time during their
procedure. All refrained because any pain was not severe or quickly subsided, the
endoscopist indicated the cramping was almost over, and they wanted to finish the
colonoscopy without medications.
The mean duration of the 26 colonoscopies during which no medication was used was
22.6 ± 8.9 minutes (scope in to scope out) ([Table 2]). This was not significantly different from the baseline average procedure time
of the four endoscopists (21.6 minutes, P = 0.23). Thirteen individuals (50.0 %) had diverticulosis and a mean of 2.1 ± 1.8
polyps were removed in 11 patients (42.3 %). Polyps were a mean of 4.9 ± 3.8 mm and
included sessile serrated polyps/adenomas, tubular adenomas, hyperplastic polyps,
and serrated adenomas. The endoscopist noted difficulties during three procedures
(11.5 %), which included performing difficult maneuvers to retrieve polyps, frequent
repositioning, and administering abdominal counterpressure. One of these individuals
had a history of appendectomy and cholecystectomy. All had diverticulosis, though
diverticulosis was not significantly associated with difficulties (P = 0.22). There was no other history that might impact the difficulty of the procedure.
The mean age of these three subjects was 75.0 years, which was significantly different
from the 24 with no difficulties (62.5 years, P = 0.02).
Patient motivations for choosing VR
Motivations for using VR instead of pharmacological sedation were assessed on a scale
of 1 to 10 (1 = “this outcome did not motivate me to try VR,” 10 = “this outcome strongly
motivated me to try VR”) ([Fig. 1]). Among the 26 patients who did not request medication, being able to drive and
perform normal activities following the procedure was the strongest motivator for
choosing VR (mean score 7.5 ± 2.5/10), followed by not wanting to receive narcotics
(7.4 ± 3.0/10). Moderate motivators included not thinking the procedure is uncomfortable
(6.8 ± 2.4/10) and not needing an escort for pick-up (5.8 ± 3.5/10). In addition to
these options given in the questionnaire, one subject added “no nausea” as a 10/10
motivator, and another reported “less medication in my body” as a 9/10 motivator.
Fig. 1 Mean scores for motivations for choosing virtual reality instead of pharmacological
sedation during colonoscopy. Blue indicates individuals who completed colonoscopy
using virtual reality and no pharmacological rescue (n = 26). Green indicates the
individual who requested pharmacological rescue after initiating colonoscopy with
virtual reality (n = 1). Y-axis: Score. 1 = “This outcome did not motivate me to try
virtual reality.” 10 = “This outcome strongly motivated me to try virtual reality.”
Error bars indicate standard deviation.
Patient satisfaction with VR
Subjects who completed their colonoscopy without medication rated their satisfaction
with their colonoscopy/VR experience at a mean of 7.3 ± 2.5/10 ([Table 2]). Satisfaction was weakly associated with pain (r = –0.49) and discomfort (r = –0.46) but did not correlate with the strength of a patient’s motivation to use
VR (r = 0.13).
When asked if they would choose VR instead of pain medication for future colonoscopies,
18 of 26 subjects who did not request medication (69.2 %) said “yes,” and seven (26.9 %)
said “maybe,” Only one subject (3.8 %) indicated that she would not choose VR for
future colonoscopies. The subjects’ likelihood of recommending VR during colonoscopy
to a friend/family member was 7.4 ± 2.4/10 (1 = not likely, 10 = very likely) ([Table 2]).
Endoscopist experience with VR
Endoscopists rated their overall experience with VR subjects at a mean of 8.6 ± 1.8/10
(1 = poor, 10 = excellent). This number increased to 9.0 ± 0.8/10 for 22 procedures
during which no difficulties were noted and dropped to 5.0 ± 3.0/10 for the three
procedures with difficulties. All endoscopists reported that they would be comfortable
incorporating VR as a pain-management strategy into their colonoscopy practice (N = 25:
19 – yes, I would be comfortable; 6 – yes, but I would use it as an adjunct therapy).
Discussion
In this pilot study of VR as an alternative to pharmacological sedation in routine
colonoscopy, 96.3 % of subjects completed their colonoscopy using VR without any sedative
or narcotic medications. Patient-reported pain was minimal, satisfaction was high,
and the majority of patients indicated they would use VR instead of conscious sedation
for future colonoscopies. Effective pain management is crucial for colonoscopy patients
because high levels of pain decrease colonoscopy completion rates and willingness
to return for repeat colonoscopies [6]
[7]. Our findings corroborate other studies that point to VR as an effective anxiolytic
and analgesic that does not compromise patient care or satisfaction [4]
[5].
Although we have shown that VR may be used as a substitute for medication in motivated
individuals, in 24 % of cases, endoscopists reported that they would prefer to use
VR along with medications. This strategy may enhance the effects of lower doses of
narcotics and anxiolytics. Such adjunctive use of VR during colonoscopy has been shown
to be feasible [8], and future studies should investigate whether VR decreases the medication dose
required. Opioid shortages have occurred due to supply chain disturbances. These situations
necessitate the optimization of non-pharmacological therapies and prioritizing indications
for opioid use [9]. Screening colonoscopies would be considered low priority, and VR could play an
important role in mitigating colonoscopy-associated pain and anxiety during these
times. VR may even be a safer alternative than an unfamiliar analgesic, as introducing
unfamiliar drugs increases the risk of medical error [10].
A strategy that incorporates VR into a colonoscopy workflow is also likely to offer
systemic cost savings. This can be attributed to decreased medication costs, reduced
time and resources required in the recovery room, and reduced costs associated with
a day of missed work for both the patient and escort. As need for an escort and concerns
about sedation are common barriers to obtaining colonoscopy [1], a non-pharmacological pain-management strategy could make colonoscopy more accessible
and ultimately, more utilized.
Conclusion
In conclusion, our findings indicate that VR is a feasible alternative to conscious
sedation during colonoscopy for patients motivated to avoid sedatives and narcotics.
