Table 1 Systematic review of virtual reality in intensive care medicine

Adult intensive care medicine

 Laghlam et al. (2021, France) *

[25]

200 (99/101)

Randomized, prospective trial

2

ICU patients

68.0 (60.0–74.8)

Surgery time

During the removal of chest drains after cardiac surgery

VR session

Inhaled equimolar mixture of N₂O and O₂ (Kalinox®)

VR did not reach the statistical requirements for a proven non-inferiority vs. Kalinox® in managing pain and anxiety during chest drain removal (mean difference in analgesia/nociception index − 0.6 [− 3.6 to 2.4], including the non-inferiority margin of 3). Moreover, VR was less effective based on Numeric Rating Scale (VR: 5.0 [3.0–7.0] vs. Kalinox: 3.0 [2.0–6.0], p = 0.009)

 Lee and Kang (2020, South Korea) *

[31]

48

(24/24)

Randomized controlled trial

2

ICU patients

66

30 min (once)

30 min before bedtime (9–11 PM) on the day of ICU admission

Meditation using a head-mounted display for virtual reality

No meditation

The experimental group reported significantly higher subjective sleep quality than the control group (p = 0,002). Activity tracker assessment indicated that total sleep time and light sleep time did not differ between the groups (p = 0,071). However, the awake time was shorter, deep sleep time was longer and sleep efficiency (p = 0.008) was significantly higher (p = 0.018) in the experimental group than in the control group

 Vlake et al. (2021, Netherlands) *

[50]

104

(57/47)

Randomized controlled trial

2

ICU patients

61

10 min

Shortly after being discharged from the ICU, while still being treated in the hospital ward

ICU-VR group receiving ICU-VR

Control VR group receiving a nature VR environment

ICU-specific virtual reality patients experienced higher immersion, cybersickness scores were low, and no changes in vital signs were observed. They also reported reduced posttraumatic stress disorder and depression scores and better mental health from 2 days until 1 month after initial exposure(Short Form-12 Mental 2-Component Scale: ICU-specific virtual reality, 57 [36, 67] vs control virtual reality, 47 [26, 63]; p < 0.01). Six months after exposure, this effect was still present for post-traumatic stress disorder and depression, but not for mental quality of life

 Vlake et al. (2021, Netherlands)

[76]

45

(15/15/15)

Randomized controlled trial

2

Healthy participants

61 (45-75)

10:55 min

n/a

Head-mounted display virtual reality group (n = 15)

2D group (n = 15), and crossover group (n = 15)

ICU-specific virtual reality appears safe and more immersive than 2D, implicating that ICU-specific virtual reality is feasible for clinical use. Volunteers in the crossover group experienced a higher total presence (p < 0.001) when using head-mounted display virtual reality, expressed as a higher sense of presence (p < 0.001), more involvement (p < 0.01), and more experienced realism (p < 0.001). One should however be aware of simulator sickness-related symptoms

 Navarra-Ventura et al. (2021, Spain) *

[45]

72

(34/38)

Randomized controlled trial

2

ICU patients

69.1 [35.7–85.9]

15–20 min

ICU stay

VR-based neurocognitive intervention

Standard ICU care

VR-based neurocognitive stimulation may help improve short-term working memory outcomes. Patients in the VR group had better working memory scores (p = 0.009, d = 0.363) and showed up to 50% less non-specific anxiety (11.8% vs. 21.1%) and depression (5.9% vs. 10.5%)

 Vlake et al. (2022, Netherlands) *

[51]

89

(45/44)

Randomized controlled trial

2

ICU patients

58 ± 11

14 min

Post-COVID-19 3, 4, and 6 months after hospital discharge

VR-intervention 3, 4, and 6 months after hospital discharge

Standard follow up

ICU-VR improves satisfaction and reduces the prevalence of psychological distress after ICU treatment. ICU-VR did not improve psychological recovery or quality of life

 Merliot‑Gailhoustet et al. (2022, France) *

[29]

60

(60/0)

Randomized controlled trial

2

ICU patients

62 [51, 69]

15 min per session

ICU stay

4 relaxation sessions (standard relaxation with television/radio, music therapy, and

two virtual reality systems with real motion pictures

or synthetic motion pictures)

n/a

VR systems were associated with a significant decrease in overall discomfort, stress, anxiety, pain, and in lack of rest. VR relaxation therapy is a promising, safe, and effective solution to improve overall discomfort in ICU patients

 Bodet-Contentin et al. (2022, France) *

[21]

88

(88/0)

Randomized controlled trial

2

ICU caregivers

n/a

8 min

Break time in the ICU

A half-hour break time including an 8-min-long VR session

Usual break time

VR reduced the fatigue score after the break time significantly and increased the feeling of disconnection from the work environment

 Chiang et al. (2021, Taiwan) *

[14]

60

(30/30)

Prospective, controlled, 2:1 randomized pre-pre-postudy

2

Healthcare providers

21—30

15 min

Training

VR-based learning on tracheostomy

care

Text-based training

VR training increased self-efficacy, including the aspects of familiarity and confidence, and reduced anxiety about tracheostomy-related knowledge and care skills. The benefits persisted until 3 to 4 weeks later

 Colt et al. (2001, United States) *

[13]

9

(5/4)

Nonrandomized trial

3

Bronchoscopist novices

n/a

n/a

Before and after 4 h of group instruction and 4 h of individual unsupervised practice

VR to practice performing inspection flexible bronchoscopy

4 skilled physicians performing bronchoscopy without previous VR practice

A short, focused course of instruction and unsupervised practice using a virtual bronchoscopy simulator enabled novice trainees to attain a level of manual and technical skill at performing diagnostic bronchoscopic inspection similar to those of colleagues with several years of experience (speed: p = 0,33, accuracy: p < 0,05)

 Gerber et al. (2019, Switzerland)

[77]

33

(33/0)

Observational study

3

ICU patients

63 (32-83)

5 min

3 times:

ICU admission, during ICU stay, and 3 months after discharge

Video presenting aquatic worlds and landscapes for 5 min

n/a

VR was recalled better (84,4%) than the rest of the ICU stay (30.3%) and well accepted. The decreased respiratory rate during stimulation indicates a relaxing effect of VR (Pre-3ICU session − 1.34 (3.93) breath/min, p = 0,039; ICU session -0,56 (1, 79), p = 0.048; Follow-up session − 1.88 (4.65), p = 0.021)

 Mosso-Vázquez et al. (2014, Mexico) *

[23]

67

(67/0)

Observational study

3

Patients after cardiac surgery

n/a

30 min

Within 24 h after cardiac surgery

30-min VR simulation designed for pain management

n/a

A heavy positive correlation existed between breathing rate and Likert ratings (R² = 0.259), and a moderate correlation was found between mean arterial pressure and Likert ratings (R² = 0.087) and heart rate and Likert ratings (R² = 0.049), all of which indicated lower pain and stress within patients

 Jawed et al. (2021, United States) *

[36]

36

(36/0)

Observational study

3

15 patients / 21 health care providers

Patients 60.8 ± 10.9

health care providers 32.5 ± 7.8

15 min

Any time

15-min session showing a relaxing beach scene

n/a

There was a high level of acceptance of VR, reducing anxiety, with minimal side effects

 Markus et al. (2009, United States) *

[26]

10

(10/0)

Observational study

3

Burn patients

n/a

6 min (2-9 min)

n/a

Measurement of staff resources needed to implement VR

n/a

A mean of 59 staff time minutes (S.D. 18; range 29–85) was required for set-up, instruction, VR therapy, and cleaning. Set-up required the most time, averaging 23 min

Instruction, participation, and clean-up means were 6, 13, and 16 min, respectively

 Gerber, et al. (2019, Switzerland)

[78]

45

(45/0)

Observational study

3

Healthy participants

59 (22–87)

10 min (two times)

n/a

Two times with the head-mounted display (i.e., virtual nature and urban VR stimulation) and once with the gold standard (control condition), a classical ICU TV screen (movie), with each interaction lasting 10 min

n/a

The results showed that the natural environment had the highest positive and restorative effect (none = 0 and high = 1) on the physiological and psychological state of healthy subjects (mean 0.773; SD 0.142), followed by the urban environment (mean 0.65715; SD 0.187) and the ICU TV screen (mean 0.5854; SD 0.136). VR might reduce sensory overload and deprivation and thus prevent neurocognitive late effects

 Gomes et al. (2019, Brasil) *

[47]

60

(60/0)

Observational study

3

ICU patients

47 ± 17

6 min

During physical therapy sessions

Nintendo Wii™ (Nintendo of America Inc.™, USA) gaming system

n/a

Virtual rehabilitation elicited light to moderate levels of activity in intensive care unit patients

 Haley et al. (2022, United States) *

[30]

10

(10/0)

Observational study

3

Mechanically ventilated patients

58 (49-66)

5 min

n/a

VR session with a cinematic video of an outdoor green space or blue space with 360° visual range of motion

n/a

No occurrences of the predefined safety events, and no occurrences of cybersickness. The use of a visual analog scale to measure anxiety levels was feasible for this pilot study

 Hoffman et al. (2008, United States) *

[27]

11

(11/0)

Observational study

3

Burn patients

27 (9-40)

3 min

During burn wound debridement in the hydrotherapy tank

3-min sessions with no VR distraction (i.e., standard premedication only) and 3-min treatment session with VR in randomized order

n/a

Patients reported significantly less pain when distracted with VR [e.g., "worst pain" ratings during wound care dropped from "severe" (7.6) to "moderate" (5.1), p = 0,015]. The 6 patients who reported the strongest illusion of "going inside" the virtual world reported the greatest analgesic effect of VR on worst pain ratings, dropping from severe pain (7.2) in the no VR condition to mild pain (3.7) during VR (p < 0,05)

 Nijland et al. (2021, Netherlands) *

[20]

66

(66/0)

Observational study

3

ICU nurses

42.4 (12.2)

10 min (no limitation on frequency)

During shift

Navigate through high-quality immersive 360-degree videos of calming natural environments

n/a

Mean perceived stress was lowered by 39.9% after the use of VRelax (mean difference = 14.0, SD = 13.3, p < 0.005). The mean score on the Perceived Stress Scale-10 was 11.4 (SD = 6.50), and the mean score on the Connor–Davidson Resilience Scale-10 was 29.0 (SD = 5.51). Sixty-two percent of the ICU nurses thought VRelax was helpful to reduce stress

 Ong et al. (2020, United States) *

[40]

59

(59/0)

Observational study

3

ICU patients

50 ± 18

5-0.20 min (up to seven sessions)

Up to seven sessions, each at least 24 h apart

Guided meditation for breath control and progressive relaxation

n/a

The virtual reality meditative intervention improved patients’ ICU experience with reduced levels of anxiety and depression (estimate = –2.17; 95% CI, –4.23 to –0.106) and depression (estimate = –1.25; 95% CI, –2.37 to –0.129); however, there was no evidence that virtual reality had significant effects on physiologic measures, pain, or sleep

 Parke, Hough, and A (2020, United States)*

[48]

20

(20/0)

Observational study

3

ICU patients

n/a

The mean intervention time was 29 min

n/a

Xbox Kinect Jintronix software targeting arm, leg, and trunk strength, range of motion, and endurance in 20 adult ICU patients

n/a

VR environment for the delivery of early mobility in patients with critical illnesses was feasible. There were no falls, lines dislodged, or medical events, and this could motivate them to continue. Fatigue was the most common reason for cessation

 Faber, Patterson, and Bremer (2013, Netherlands) *

[28]

36

(36/0)

Observational study

3

Pediatric and adult burn patients

27.7 (8-57)

One session per day (one and up to seven consecutive days)

wound care session

VR during wound care session (snow World)

n/a

Results from the present study suggest that VR continues to be effective when used for three (or possibly more) treatments during severe burn wound debridement

 He et al. (2022, China) [42] *

141

(71/70)

Cohort study

3

ICU patients

52.86 ± 17.96

n/a

ICU stay

5G + VR visitation channels to communicate with the families

No 5G + VR visitation

After 5G + VR visitations, the patients’ HADS scores and the proportion of delirium decreased significantly. No significant difference in the length of ICU stay

 Vlake, van Genderen, et al. (2020, Netherlands)

[79]

44

(44/0)

Cohort study

3

ICU patients

61 (22-76)

n/a

n/a

Assess the needs, expectations, and wishes of ICU survivors to receive information (brochure, video film/VR)

Patients

Patients suffering from psychological PICS need information, and have no desire to use an information brochure but are willing to receive information via digital content such as a video film/VR (54% of PICS patients)

 Naef et al. (2022, Switzerland) *

[37]

31

(31/0)

Mixed methods study

3

ICU patients and nursing experts

32 and 73

As long as the participants prefer

ICU stay

Visual and auditory stimulation

n/a

Patients and experts agreed that receiving visual and/or auditory stimuli would benefit patients. Visual stimuli should not exceed 10–15 min, while auditory stimuli should not exceed one hour

 Blair et al. (2019, United States)

[80]

1

Case report

4

ICU patient with veno-venous extracorporeal membrane oxygenation

21

As long as the patient prefers

Hospital stay

VR-experience with “Pebbles the Penguin”

n/a

The patient reported her anxiety subjectively improved with virtual reality

 Esumi et al. (2020, Japan) *

[24]

1

Case report

4

ICU patient with compartment syndrome

40

30 min (3 sessions)

Any time

VR program simulates the experience of being at the beach beside a calm sea on a sunny day

n/a

Three sessions of virtual reality analgesic therapy over 2 days produced sustainable analgesic effects, which led to a 25–75% dose reduction in fentanyl administration and the concomitant alleviation of respiratory depression

 Chillura et al. (2020, Italy)

[74]

1

Case report

4

Post-ICU patient with ICUAW

56

2 exercises, each 55 min (once a day, 6 days a week, for 2 months)

After 2-month conventional training

Physiotherapist-supervised robotic rehabilitation protocol, in addition to the already practiced conventional and respiratory physiotherapy

n/a

At the discharge (6 months after the admission), the patient reached the standing station and was able to ambulate with double support

 Vlake et al. (2020, Netherlands) *

[52]

1

Case report

4

ICU patient

57

(twice)

17 days after hospital discharge

n/a

One week after receiving ICU-VR, levels of PTSD, anxiety, and depression had normalized, and stayed normalized until 6 months after discharge

 Gerber et al. (2017, Switzerland)

[72]

37

(37/0)

Proof-of-concept study

n/a

Healthy participants

48 (20-85)

5 min (3 times)

n/a

Three 2D nature videos, every five minutes in length, played as side-by-side videos

n/a

The VR stimulation led to a reduction in heart rate (p = 0. 049) and blood pressure (p = 0.044). The fixation/saccade ratio (p < 0.001) was increased when a visual target was presented superimposed on the videos (reduced search activity), reflecting enhanced visual processing. Overall, the VR stimulation had a relaxing effect as shown in vital markers of physical stress and participants explored less when attending the target

 Small et al. (2015, United Kingdom)

[81]

25

(25/0)

Randomized controlled trial

n/a

Burn patients

study protocol

Dressing change time

During dressing change

1. Interactive VRET plus conventional analgesics

2. Passive VRET with conventional analgesics

Conventional analgesics alone

Study protocol, the results are not yet available. The study evaluates the effects of VR on pain during and after dressing changes compared with traditional analgesia during dressing changes in a burns unit

 Rousseaux et al. (2020, Belgium) *

[34]

100

(25/25/25/25)

Randomized controlled trial

n/a

Cardiac surgery patients

study protocol

20 min (twice)

One day before surgery, one day after surgery

3 groups: hypnosis, VR, or virtual reality hypnosis

Daily care only

Study protocol. The study will evaluate the influence of VR applications on patients’ anxiety, fatigue, pain, and phenomenological experience

 Naef et al. (2021 Switzerland)

[82]

aimed 920

Randomized controlled trial

n/a

ICU patients

study protocol

30 min (3 times a day)

Three times per day, morning, midday, and evening

In addition to the standard ICU care relaxing VR stimulation three times a day

Standard ICU care

Study protocol. The hypothesis is that the VR application may reduce the incidence of delirium

 Suvajdzic et al. (2018, United States) *

[39]

study protocol

Case–control study

n/a

ICU patients with delirium

study protocol

study protocol

Study protocol

An immersive digital reality-augmenting system consisting of a commercially available VR headset to deliver a calming experience through software-facilitated meditation practice

No VR

Study protocol. The hypothesis is that our virtual reality therapy system would lower the occurrence of delirium in patients admitted to intensive care units

Pediatric intensive care unit

 Hoffman et al. (2019, United States) *

[8]

48

(48/0)

Randomized controlled trial

2

Pediatric ICU burn patients

12 (16–17)

12.89 min (4 days)

During wound care: repeatedly alternating between no vr and yes vr every 5 min

VR during the first 5 min of wound care. VR, patients played SnowWorld, an interactive 3D snowy canyon in virtual reality during some portions of wound care

No VR during the first 5 min of wound care

VR significantly reduced children's “worst pain” ratings during burn wound cleaning procedures in the ICU on Day 1. Worst pain during No VR = 8.52 (SD = 1.75) vs. during Yes VR = 5.10 (SD = 3.27), t₍₄₇₎ = 7.11, p < 0.001, SD = 3.33, CI = 2.45–4.38, Cohen's d = 1.03 (indicating large effect size). Patients continued to report the predicted pattern of lower pain and more fun during VR, during multiple sessions

 Agasthya et al. (2020, United States) *

[19]

15

(7/8)

Randomized controlled trial

2

Pediatric residents

n/a

19 min

Training

9-min VR tutorial that outlined the steps involved in preparation for pediatric airway intubation

The non-VR group listed intubation steps from memory

The VR group had seven trainees (47%) and scored similarly to the other group based on checklist items (50.5% vs 50.8%, P = 1)

 Umoren et al. (2021, United States)

[83]

274 (91/95/88)

Randomized controlled trial

2

Health care providers

38 ± 9

n/a

Training

VR simulation + digital guide (n = 91)

Video + digital guide (n = 95)

Digital guide only (n = 88)

Neonatal resuscitation skills pass rates were similar among the groups at the 6-month follow-up bag and -mask ventilation (BMV) skills check (VR 28%, video 25%, control 22%, p = 0.71), objective structured clinical

examination (OSCE) A (VR 76%, video 76%, control

72%, p = 0.78) and OSCE B (VR 62%, video 60%, control 49%, p = 0.18). Relative to the immediate postcourse assessments, there was greater retention of BMV skills at 6 months in the VR group (− 15% VR, p = 0.10; − 21% video, p < 0.01, –27% control, p = 0.001). OSCE B pass rates in the VR group was numerically higher at 3 months (+ 4%, p = 0.64) and 6 months (+ 3%, p = 0.74) and lower in the video (− 21% at 3 months, p < 0.001; − 14% at 6 months,

p = 0.066) and control groups (− 7% at 3 months, p = 0.43; − 14% at 6 months, p = 0.10). In a follow-up survey, 95%

(n = 65) of respondents in the VR group and 98% (n = 82) in the video, group would use their assigned intervention

again

 Yang et al. (2022, South Korea) *

[17]

83

(29/28/26)

Non-randomized trial

3

ICU staff

n/a

50 min

Training

Neonatal resuscitation gamification program using immersive virtual reality

Only resuscitation program lectures

Neonatal resuscitation knowledge [F (2)  = 3.83, p = 0.004] and learning motivation [F (2) = 1.79, p = 0.025] were significantly higher in the virtual reality and simulation groups than in the control group. Problem-solving ability [F (2)  = 2.07, p = 0.038] and self-confidence [F (2)  = 6.53, p < 0.001] were significantly higher in the VR group than in the simulation and control groups. Anxiety [F (2)  = 16.14, p < 0.001] was significantly lower in the simulation group than in the VR and control groups

 Badke et al. (2019, United States) *

[54]

28

(28/0)

Observational study

3

PICU patients

9 (7–13.3)

max. 15 min

n/a

Choice of developmentally appropriate VR experiences, ranging from serene natural landscapes, such as safari or scuba diving, to more thrilling videos, such as snowboarding and roller coasters

n/a

One hundred percent of participants enjoyed using virtual reality, and 84% reported a preference to use virtual reality for a longer duration. One hundred percent of parents agreed that their child enjoyed using virtual reality and 100% enjoyed watching their child use virtual reality

 Tallent et al. (2021, United States) *

[59]

9

(9/0)

Observational study

3

Caregiver of pediatric ICU patients

31.1 [23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40]

max. 15 min

On medical rounds

Join medical rounds of their kids in PCICU

n/a

VR can be successfully implemented for family engagement without increased burden on staff. It did not increase rounding time (p = 0,673), and workload impact perceptions improved after intervention (p =  < 0.001)

 Farra et al. (2019, United States) *

[18]

93

(n/a)

Observational study

3

Staff related to neonatal ICU evacuation

25–31

10 min (at 0, 4, 8, and 12 months)

4 times: 0, 4, 8, and 12 months

Virtual reality simulation (VRS) emergency evacuation training

web-based clinical updates (CU)

The VRS and CU groups did not statistically differ based on the scores on the Cognitive Assessment or perceived self-efficacy. The virtual reality group’s performance in the live exercise was statistically (P < 0.0001) and clinically (effect size of 1.71) better than that of the CU group

 Ralston et al. (2021, United States) *

[15]

6

(6/0)

Observational study

3

Pediatric cardiac critical care physicians

n/a

6 min (range 4–8 min)

n/a

Pilot test of VR’s feasibility for educational and practice improvement efforts

n/a

VR might be more effective in trail training specifications

Clinicians previously unfamiliar with VR can engage in simulated acute clinical scenarios common to the pediatric CICU

 Abdulsatar et al. (2013, Canada) *

[57]

8

(8/0)

Observational study

3

Pediatric ICU patients

11 (3-18)

54.5 (15, 224) min

2 times over the 2-day intervention period in PICU

Wii™ play

n/a

VR can be safely used with critically ill children

Upper limb activity during Wii™ was significantly greater than the average daily activity (p = 0.049). Grip strength did not change significantly from baseline (p = 0.20)

 Yu et al. (2021, Republic of Korea) *

[16]

50

(25/25)

Observational study

3

Nursing students

22.40 ± 1.05

40 min

Training

Virtual reality simulation of three scenarios: basic care, feeding management and skin care and environmental management for prevention of neonatal infection

routine neonatal intensive

care unit practice

Compared to the control group, the experimental group showed significantly greater improvements in high-risk neonatal infection control performance self-efficacy (t = -2.16, p = 0.018) and learner satisfaction (t = -5.59, p < 0.001)

 Badke et al. (2022, Chicago) *

[55]

115

(115/0)

Cross-sectional study

3

Critically ill children

10 (6–13)

10 min (7-17)

ICU stay

VR headset was used to deliver 360-degree immersive experiences

n/a

83% of participants smiled, 36% laughed and 79% were highly engaged while using VR. 92% of parents reported that VR calmed their children, and 78% of participants felt that VR was calming. HRVi Minimum scores were significantly higher during VR

 Lai et al. (2021, United States) *

[58]

2

Case report

4

PICU patients

Case 1:15

Case 2: 13

Case 1: 18 min (SD 11) per session, 4 sessions

Case 2: 35 min (SD 7) per session, 2 sessions

Between usual care, when tolerable and requested by the participant

VR gaming sessions with active games (e.g., boxing, rhythmic movement to music, and exploratory adventure) and nonactive games (e.g., racing and narrative adventure)

n/a

The findings of this study suggest that VR gaming with HMDs and adaptive software is likely a feasible supplement to usual care for adolescents within the PICU, and these findings warrant further investigation. Recommendations for future studies aimed at incorporating VR gaming during early mobilization are presented herein

 Hemphill et al. (2021, United States)

[73]

1

Case report

4

Pediatric ICU patient

n/a

n/a

During physical therapy sessions

VR to encourage the child to engage in physical therapy sessions

n/a

Virtual reality encouraged the child to engage in physical therapy sessions, participate for greater durations, and directly address barriers to discharge

 Scapin et al. (2017, Brazil)

[84]

2

Case report

4

Pediatric burn patients

8, 9

15 min, 35 min, 25 min

Dressing change during balneotherapy

The child used VR to watch a game that simulated a roller coaster

n/a

The use of goggles was easy to apply and well-accepted by the children, and had a relevant effect reducing pain (pain face: case 1: 10/10 during a dressing change, 4 during VR use vs. case 2: 4 during dressing; 0 during use VR,)

 Kucher et al. (2020, United States) *

[56]

6

(6/0)

Proof-of-concept study

n/a

Total pancreatectomy and islet auto-transplant (TPIAT) surgery patients

8–18

25.6 min ( 9–90 min), individual preference (between 1 – 5 times)

After surgery

After surgery nature-based theme VR

n/a

Initial quantitative scoring systems suggest overall improvement in symptom management, and reactions by both patients and their parents were overall positive