Introduction
The application of extended reality (XR) technology has rapidly increased over the past two decades, presenting new opportunities for clinical practice and education in medicine [1]. XR is an umbrella term that encompasses virtual reality (VR), augmented reality (AR), and mixed reality (MR) technologies [1,2]. VR is defined as “a simulated experience that employs a 3D near-eye display to give the user an immersive feel of a virtual world,” often utilizing head-mounted displays (HMDs) [3,4]. In contrast to VR, which completely replaces the user’s environment with the virtual one, AR and MR blend real-world experiences with virtual elements [1,4,5]. AR overlays digital images onto the real world without interactivity, while MR allows users to physically manipulate digital content in a blended environment [1,4,5]. Fig. 1 illustrates the structural differences among these technologies. The purpose of this narrative review was to introduce the current literature on XR technology utilization to help increase its adoption in education and clinical practice in anesthesiology.
Application of XR in medical education
As simulation becomes a key aspect of medical education [6], XR technology has been gaining attention. The essential characteristics of VR, namely immersion and presence, offer learners a heightened level of engagement [3]. Compared to traditional educational methods, XR enhances learners’ motivation and improves all three domains of learning: cognitive (knowledge), psychomotor (skills), and affective (attitude) [7,8]. XR technology has mainly been used in medical education for teaching both technical skills for specific medical procedures and non-technical skills such as communication.
Technical skill education for medical procedures
Airway management
The role of simulation training in airway management education has been well-documented. Although high-fidelity 2D bronchoscopy simulators have been well-developed and studied, immersive VR simulators for other airway management skills are limited [9]. One study that employed VR simulations for Mallampati scoring and surgical cricothyroidotomy reported improvements in trainee performance and knowledge [10]. Another study utilized narrative VR to train airway device placement skills [11]. However, these studies lacked control groups, making it difficult to assess the full effectiveness of VR [10,11].
AR has shown promise in direct laryngoscopy and endotracheal intubation. In one study, AR glasses projecting text-based instructions during endotracheal intubation improved adherence to standard protocols compared with the control group [12]. Another study incorporated advanced AR technology in neonatal endotracheal intubation training. In that study, a microcamera at the tip of the laryngoscope blade captured a video of the patient’s airway, which was then projected onto the AR glasses. This significantly increased success rates, from 32% in the conventional group to 71% in the AR group [13].
Regional anesthesia and pain procedures
Considering the numerous advantages of interactive XR technology in anatomical education, XR simulators are promising for radiology-guided regional anesthesia training [8]. Proficiency in ultrasound-guided regional anesthesia requires both cognitive (sonoanatomical knowledge) and technical (transducer scanning) skills [14]. A recently developed immersive VR simulator consisting of an HMD and two motion controllers allows for simultaneously training both ultrasound image optimization and needling skills [15]. This simulator also tracks hand movements, making it a promising tool for educational feedback in regional anesthesia training. Because this simulator can replicate any sonoanatomy, it has high potential for advancing ultrasound-guided anesthesia training in the future. One group of researchers introduced a VR simulator for C-arm-guided pain procedures [16]. This interactive VR simulator reduced the procedure time, minimized C-arm usage, and increased satisfaction compared with the control group. However, its broader applicability requires further validation due to the small sample size.
XR simulators for blind-technique regional anesthesia (e.g., spinal anesthesia) have also been explored. One study reported high satisfaction with a non-interactive VR spinal anesthesia training module. The participants watched a step-by-step VR video of the spinal anesthesia process using an HMD (Fig. 2) [17]. Participants reported high satisfaction and perceived significant educational benefits. Although the sample size was large (n = 168), this study lacked a control group and did not assess the impact on procedural performance. Additional research is therefore necessary to evaluate the effectiveness of non-interactive VR simulators in regional anesthesia education.
An interactive VR spinal anesthesia simulator consisting of an HMD and two handheld motion controllers was tested by anesthesiology residents without prior experience (Fig. 3). During the first week of training, the VR group used a VR simulator, whereas the control group relied on conventional clinical observation. For the remaining three weeks, both groups continued training in the same manner. Upon completion of the four-week training, the VR group achieved higher knowledge and skill scores in spinal anesthesia performed on patients [18]. This finding is consistent with previous research showing that VR education enables long-term retention of learning experiences [7,8].
Another interactive VR simulator with haptic feedback was developed to train combined spinal-epidural anesthesia [19]. This simulator consisted of an HMD and a pencil-type haptic feedback device (Fig. 4). The virtual environment was a 3D operating room with a patient positioned for spinal anesthesia. When the needle tip (represented by the haptic feedback device) touched the skin of the virtual patient at the puncture site, a 3D model of the internal anatomy appeared. As the needle advanced into the virtual patient’s back, the system provided feedback for seven distinct sensory events, including ligamentum flavum resistance and the force required to penetrate the subcutaneous tissue. After ten simulation sessions, the puncture time stabilized at 2.4 min. The trainees reported high satisfaction and recognized the simulator as an excellent clinical substitute [19]. Considering the importance of tactile feedback in medical simulation training, particularly in combined spinal-epidural anesthesia, incorporating haptic feedback could represent a significant advancement in regional anesthesia education.
Additionally, an MR simulator for spinal anesthesia training consisting of MR glasses and a manikin has been developed (Fig. 5). With this simulator, a 3D internal image is projected onto the manikin via the MR glasses upon palpation of the puncture site to help the trainee understand the internal anatomy [20]. This MR simulator improved trainees’ performance skills, satisfaction, and confidence after training. However, due to the absence of a control group, this study could not demonstrate the superiority of MR training over traditional methods.
Vascular access
Simulation training is a crucial component of vascular assessment education. However, VR simulators designed for this purpose are still in the early stages of development. One study on a VR simulator for central vein catheterization training found that trainees using a system with an HMD and handheld controllers reported higher satisfaction than those using a manikin simulator, particularly in terms of spatial awareness and adherence to standard protocols [21]. However, 41% of the participants preferred manikins because of their superior tactile feedback. Inadequate haptic feedback remains a major limitation of current VR simulators. Although recent advances in haptic technology have shown promise, existing sensors do not replicate human tactile perception [22,23]. In this context, incorporating AR or MR technology through combining virtual elements with physical models may be a promising approach for needling skills training. For example, for one immersive MR simulator for peripheral intravenous catheterization, MR glasses are used to project internal anatomical features onto a manikin. This system was found to improve students’ confidence, satisfaction, and clinical success rates [24].
Non-technical skill education
In clinical practice, physicians require non-technical as well as technical skills and medical knowledge. XR simulation training has been widely adopted to teach healthcare professionals non-technical skills [25]. XR training is particularly promising for high-stakes and low-frequency scenarios such as anesthesia crises. This technology enables repetitive training in scenarios that are too risky, costly, or difficult to replicate through traditional methods [25], allowing for safe and effective practice without risk to patients.
Crisis management
Although airway crises are rare, the consequences can be serious; therefore, anesthesiologists must be well-prepared. One study tested scenario-based VR simulators for pediatric airway emergencies, including anaphylaxis and foreign body aspiration, among various levels of medical professionals [26]. The VR simulator provided effective cognitive learning and significant improvements in knowledge. This study also reported an enhancement of affective learning. Learners reported experiencing a degree of anxiety similar to that of a real-life event and stated that the VR simulator promoted active participation [26]. A VR decision-making game simulating an obstetric airway crisis has also been tested among anesthesiology residents. In the game scenario, the virtual patient’s vital signs changed based on decisions made at the critical junctures of managing a difficult airway in obstetrics. The VR game resulted in improved competency for the participants and improved decision-making [27].
Operating room fires are rare and considered a “never event” for most anesthesiologists and other medical staff in the operating room. However, if such an incident occurs, it must be managed according to a precise sequence of steps within the shortest possible time [28]. Education conducted on various medical professionals (including anesthesiologists) using the VR operating room fire simulator has shown dramatic improvements in trainees’ performance. In this study, 70% of the VR group performed the correct sequence of steps compared to only 20% of the control group [28]. Another study on VR training for an operating room fire demonstrated that trainees who received VR simulation training retained their skills and knowledge for a longer period [29]. Even after an 8-month washout period, the VR group exhibited superior fire management skills compared with the standard training group, which is consistent with previous reports on the long-term educational effects of VR [7,8].
Communication skills
Given that inadequate communication increases the chance of medical errors, effective anesthetic practice in terms of patient comfort and safety depends on appropriate communication skill training [30]. Patient-embodied VR, which refers to VR created from the patient’s perspective, is effective in training healthcare professionals to understand the patient’s point of view [31]. One patient-embodied VR experience was found to effectively enhance anesthesiology residents’ therapeutic communication skills, including their ability to interpret verbal and nonverbal cues [32]. Communication between surgeons and anesthesiologists in the operating room is often inadequate or inappropriate, highlighting the need for improvement [33]. A multiuser immersive VR simulator incorporating two scenarios involving medical complications was tested by anesthesiologists and surgeons. Participants reported positive feedback, noting improved communication and a better understanding of their roles within the interprofessional team [34].
Application of XR in patient care
XR content that targets patients as the users is designed to either provide distraction or information. Traditional distractive techniques such as music, movies, or clowning are limited in that they cannot fully occupy a patient’s attention, leading patients to become “distracted” during distraction therapy [35]. The immersive nature of VR, which makes users feel as though they are present in a different environment, aligns with the essence of distraction therapy as it diverts the patient’s mind from the medical procedure to the virtual world. VR distraction therapy has been successfully applied during various medical procedures [36].
Providing information is essential for reducing patient anxiety, and educating patients about the medical process increases their knowledge and positively influences their behavior and attitudes [37]. The immersive nature of VR effectively provides patients with a realistic experience, allowing them to become familiar with upcoming events, a process known as “habituation,” which enhances their ability to manage the stress associated with future events [38].
Distraction and patient education in vascular procedures
Distraction therapy is widely used during vascular procedures, particularly in pediatric patients [35,39]. The effect of VR distraction therapy during venipuncture has been extensively studied, showing that it effectively reduces patients’ pain and anxiety compared to usual care or other traditional distraction methods [40–44]. Notably, VR distraction is effective in patients with multiple previous experiences, such as those in onco-hematologic settings [43]. Despite multiple positive reports in pediatric populations, the optimal age range for VR distraction therapy during vascular procedures remains uncertain. Most studies have excluded children aged < 4 years, and only a few studies have included adolescents up to the age of 16 or 17 years [41,43,44]. Consequently, the effect of VR distraction on specific age groups such as toddlers and older children remains unexplored. Further research is required to refine or expand the age range for VR distraction therapy for vascular procedures.
Along with distraction therapy, preprocedural information is also crucial for children undergoing venipuncture [39]. Although VR distraction is well-documented, only a few studies have reported the effects of patient education VR for venipuncture. One study utilizing patient education VR with cartoon characters demonstrated an effective reduction in pain and anxiety in children, along with higher satisfaction among parents. In addition, phlebotomists reported higher levels of satisfaction and lower levels of procedural difficulty when performing venipuncture in the VR group [45]. Another trial that used VR for both information and distraction purposes simultaneously in children showed lower levels of pain and anxiety. Higher phlebotomist satisfaction and a shorter time spent on venipuncture were also reported in the VR group [46]. Notably, patient education VR significantly improves the workload of healthcare professionals by reducing procedural difficulty and shortening the time required for the procedure [45,46]. This may indicate the value of pre-procedural VR education over VR distraction in children.
Considering that the favorable effects of VR therapy in pediatric venipuncture have been consistently reported and inhalation induction is associated with significant risks for both patients and healthcare professionals, anesthesiologists may consider transitioning to a new era of preoperative VR-assisted venous access as a replacement for inhalation induction in pediatric patients [47–49].
Burn wound care
Burn wound care often requires anesthetic support due to the extreme intensity of pain, which can also lead to significant mental trauma for patients. A recent survey conducted among American Burn Association Centers showed that 37% of centers adopted VR therapy in clinical practice [50]. The use of VR during burn-dressing changes has been reported to effectively reduce pain and decrease the required opioid dose in both pediatric and adult patients [51–53]. VR therapy reduces pain as well as fear and anxiety in children undergoing burn dressings [54]. A meta-analysis revealed that unlike immersive VR, 2D video does not significantly affect pain intensity [53]. Many burn-dressing trials have employed a VR game called SnowWorld, which is specifically designed to help burn patients by featuring ice-cold environments and objects such as snowmen [52,53]. The successful effects of this VR game suggest a need for tailored VR content design, even in non-informative VR, where the sole intention is distraction.
Preoperative patient education
Preoperative anxiety is common, and preoperative education is known to mitigate anxiety [37]. The positive effects of patient education using XR on preoperative anxiety have been reported in multiple trials with only a few exception [55–60]. In contrast to the other VR studies, Eijlers et al. [61] reported no reduction in anxiety in pediatric patients receiving preoperative VR education [57,58]. The duration and content of the VR intervention may have contributed to these differing results. The session lasted 15 min and featured realistic medical professionals, while other studies used shorter sessions lasting 3–4 min with animated characters tailored for children [57,58,61].
Although most trials have consistently reported the positive effects of preoperative XR education on anxiety, notable differences exist between age groups. In these studies, older adults tended to have lower participation rates. For instance, a colorectal cancer surgical study found that 62% of screened patients refused to participate, and another adult trial reported a 32% refusal rate [55,60]. This contrasts with the 3%–4% refusal rates observed in pediatric trials [57,58]. This discrepancy may be because older adults are more reluctant than younger individuals to adopt new technologies [62]. These age-related differences in XR acceptance are important for clinicians when considering the use of XR technology in adults.
Patient education using AR has also recently been introduced into clinical practice. AR technology blends real and virtual worlds. During AR education, patients can see and interact with their real hospital environment while virtual objects are overlaid onto the real world through AR glasses. In contrast, VR education immerses patients in a virtual world via an HMD, disconnecting them from the actual hospital environment [63]. AR-based patient education effectively reduces preoperative anxiety compared to standard procedures [60,64]. In addition, participants in AR education trials have assessed AR programs as enjoyable and expressed a desire to repeat the experience [60,64].
As only one trial has investigated the optimal timing for preoperative patient education, our understanding remains incomplete. Education immediately before surgery is more effective in children [65]. In contrast, for adults, earlier education may be more beneficial, as previous trials have provided education days or weeks prior to surgery, and parents reported a preference for earlier education for their children [55,56,65]. Further research is needed to clarify these findings.
Induction of general anesthesia
Distraction therapy is an important method for alleviating anxiety during general anesthesia induction in pediatric patients, for which toys, clowns, and games using smartphones or tablet PCs have been used [66]. Playing interactive VR games with an HMD upon arrival in the operating room has been reported to reduce children’s anxiety during the immediate pre-induction period and the induction process of general anesthesia [67]. Notably, the children in the VR group exhibited lower anxiety levels even when they were not playing the VR game or wearing the HMD. The participants experienced reduced anxiety after a brief practice session in the waiting area before playing the VR game in the operating room. Another study that implemented VR video distraction therapy during transfer to the operating room reported a significant reduction in children’s fear and anxiety [68]. Playing an interactive game using AR glasses during the induction of general anesthesia has shown similar results. Children who experienced the AR game reported high engagement and satisfaction scores. In addition, caregivers rated the effectiveness of AR in reducing their children’s anxiety as high [69].
Distraction during regional anesthesia
The application of XR distraction therapy during the maintenance period of regional anesthesia or monitored anesthesia care has effectively reduced patient anxiety and/or increased patient satisfaction.
Two studies conducted on patients undergoing cesarean section under spinal anesthesia, in which sedative use was relatively restricted, showed lower anxiety levels in the VR group [70,71]. Patient satisfaction was higher in the VR group than in the control group in one study, whereas satisfaction levels were the same in another [70,71]. Among patients receiving peripheral regional anesthesia, the VR group exhibited significantly lower anxiety levels and fewer hemodynamic changes during surgery than the control group. Patient satisfaction was higher in the VR group immediately after surgery and remained elevated two months later [72]. In this study, preoperative midazolam was administered to all patients according to the center’s routine protocol, which prevented accurately evaluating the potential of XR technology to reduce medication dosages.
Recent trials have also compared pharmacological sedation with XR distraction therapy. In a study of patients who received spinal anesthesia, the VR group achieved equivalent anxiety reduction without supplemental intravenous sedatives and reported higher satisfaction [73]. Another trial involving patients undergoing a brachial plexus block found that the VR group required significantly less midazolam and experienced higher patient satisfaction [74]. Another trial compared the effects of pharmacological premedication to those of intraoperative VR therapy [75]. The VR group showed lower anxiety scores during the operation and PACU stay and higher patient satisfaction than the control group, which received midazolam as a premedication [75]. These findings suggest that XR therapy is a viable replacement for pharmacological sedation in patients undergoing surgery with regional anesthesia.
Postoperative pain control
Postoperative pain is a highly prevalent clinical concern. Commonly used drugs for postoperative pain control, such as opioids, often have side effects including nausea, vomiting, and respiratory depression. Previous studies showing the positive effects of XR on painful medical procedures suggest its potential to aid in postoperative pain management [53,76]. However, the effects of XR on acute postoperative pain control remain controversial.
One study investigating the impact of a VR intervention on acute postoperative pain in patients undergoing head and neck surgery found that the VR group had lower pain visual analog scale (VAS) scores and reduced opioid consumption than the control group, which received a smartphone intervention [77]. Another trial investigating the effect of preoperative VR intervention on postoperative pain in patients undergoing gynecological surgery found that the VR intervention was negatively correlated with postoperative VAS scores over the first 24 h and resulted in better sleep quality and a lower incidence of nausea [78]. In contrast, a recent study involving patients undergoing hip arthroplasty showed no effect of VR therapy on postoperative opioid consumption or pain scores compared with the control group. In that study, the VR group used a 3D immersive VR relaxation and distraction program with a mindfulness game, whereas the control group received a sham VR treatment involving a short nature film [79].
Chronic pain management
Chronic pain is clinically challenging and requires a multidisciplinary treatment approach. Integrating XR as a complement to conventional therapies can potentially improve overall pain management outcomes.
During the COVID-19 pandemic, a double-blind randomized trial was conducted involving 179 adults with self-reported chronic low back pain. The trial compared an immersive VR program in pain relief skills with a sham VR program. The pain-relief skills VR, which consisted of a skill-based self-management program, demonstrated a higher incidence of meaningful reductions in pain intensity and pain-related interference with activity, mood, and stress [82]. The same group reported that these favorable results were maintained throughout the 24-month follow-up period [83]. However, as the possible mechanism underlying this long-lasting effect was not addressed in the study, the results should be interpreted with caution. Several trials have investigated the effect of rehabilitation exercise VR on chronic musculoskeletal pain. While a reduction in pain intensity following VR therapy has been frequently reported, its effect on range of motion or disability levels remains inconclusive [84].
Multiple pharmacologic and non-pharmacologic modalities have been used to treat neuropathic pain; however, due to the complexity of the pathophysiology, evidence supporting these modalities is limited. In addition to traditional multimodal therapy, VR therapy has been used in patients with phantom limb pain and complex regional pain syndrome (CRPS). A systematic review on VR applications in phantom limb pain from 2024 indicated that all studies measuring pain intensity as an outcome consistently reported a decrease in mean pain intensity after a VR session [85]. However, the long-term effects of VR therapy on phantom limb pain have not been adequately studied. Because the mechanism of phantom limb pain is not yet fully understood, the mechanism of VR therapy for this condition remains unclear, although it may be similar to that of mirror therapy [85]. Most trials investigating VR therapy for CRPS have been based on the concept of virtual embodiment. By watching and moving or being touched on their real body synchronously with the virtual body, individuals can experience the illusion that the virtual body is their own [86]. However, the results of VR therapy for CRPS remain controversial. Won et al. [87] reported no improvement in pain scores after virtual mirror therapy. However, two other trials reported that the reduction in CRPS following VR sessions depended on the mode of therapy, such as heartbeat synchronization or the transparency and size of the virtual body [88,89]. Considering the complexity of the pathophysiology and management of neuropathic pain, understanding the effects of XR on neuropathic pain requires further investigation.
Intensive care unit
XR has the potential to enhance patient experiences in the intensive care unit (ICU) and improve outcomes; however, research on its application in this setting remains limited and further investigation is required for a clearer understanding of its short- and long-term impacts.
Patients in the ICU often experience neuropsychological effects, such as anxiety and delirium, and may even experience psychological sequelae such as post-traumatic stress disorder (PTSD) after discharge. Merliot-Gailhoustet et al. [90] reported that VR systems with relaxation content resulted in a significant decrease in anxiety and improved overall discomfort. The effect of VR in mechanically ventilated patients was examined using a small sample size. VR content featuring outdoor scenes has been shown to be a feasible option for managing anxiety without complications [91]. ICU patients’ quality of sleep may also be improved with VR therapy. For patients admitted to the ICU after cardiac surgery, the use of meditation VR before sleep resulted in improved sleep quality, including fewer instances of waking and longer periods of deep sleep [92]. A group of researchers also tested the effects of VR therapy conducted after discharge from the ICU. Participants were randomly assigned to the ICU-specific information VR or control VR (nature scene) group. The ICU-specific VR group showed lower PTSD and depression scores than the control group. This difference was evident two days after the VR session and was maintained until the 6-month follow-up [93]. However, this study had a small sample size and only 30 patients completed the 6-month follow-up; therefore, these results should be interpreted with caution and further studies are needed.
Family support plays a crucial role in improving the emotional well-being of ICU patients. When physical visits are restricted or not possible, VR enables patients to have virtual visits with loved ones. During the COVID-19 pandemic, a cohort study investigated the effects of VR family visits on ICU patients. The VR visitation group showed a significantly lower incidence of delirium and lower scores on the Hospital Anxiety and Depression Scale than the control group, which did not receive family visits [94].
Limitations and challenges of XR applications
Despite its theoretical advantages and the growing body of evidence supporting its benefits, XR technology in anesthesia faces several clinical and educational limitations. First, cost-effectiveness analyses and financial reimbursements are limited. Most studies on XR technology in clinical practice have focused on short-term outcomes, leaving its economic impact underexplored [95]. The lack of financial reimbursement poses a significant barrier given the high costs associated with XR systems, personnel, and infrastructure [95,96]. Without reimbursement, widespread clinical adoption remains impractical, although prices are expected to decrease as the technology evolves. Securing reimbursement through a cost-benefit analysis is essential for overcoming this challenge. Second, XR technology can cause adverse effects such as cybersickness, dizziness, and headaches [7,96,97]. These side effects may reduce the effectiveness of treatment and education. A more refined selection of hardware and content designs could help to mitigate this issue. Third, access to XR technology may be limited to specific regions or socioeconomic groups. While XR has the potential to promote healthcare equity by providing medical services and educational opportunities in underserved areas or populations, the high costs of XR systems and disparities in internet access may limit its adoption in populations that require it the most [97,98]. Solving this issue is challenging and requires collaboration among healthcare providers, policymakers, and researchers [98]. Fourth, education and technical support are insufficient [99]. Healthcare professionals have limited opportunities to learn how to use XR technology, which can lead to a lack of confidence and thus hinder its practical implementation. Additionally, technical support is insufficient in many settings. Overcoming these challenges requires a cultural shift towards enhanced education, training, and stronger support for healthcare professionals.
Conclusion
Despite its limitations, XR has significant potential to improve patient outcomes and advance medical education. From the learner’s perspective, XR technologies can enhance the experience of both knowledge acquisition and skill training. In clinical practice, XR can help alleviate patient anxiety and pain by presenting a viable alternative or adjunct to sedatives and opioids. Overcoming several challenges, such as financial reimbursement barriers, is essential for the broader implementation of XR in anesthesia.
PDF Links
PubReader
ePub Link
XML Download
Full text via DOI
Download Citation
Print
