Regional anesthesia combined with virtual reality hypnosis for extended orthopedic surgery: two case reports

Background: Virtual reality hypnosis is a combination of visual immersion in a virtual reality environment and clinical hypnosis. It can be used in addition to conventional techniques, for sedation and pain management during wound care. Patients undergoing painful and long-lasting procedures under regional anesthesia could also benefit, from this technique alleviating the need for sedative-hypnotic medication. Case presentation : Two patients with relative contraindications for general anesthesia underwent lengthy orthopedic surgery of the upper limbs under regional anesthesia with additional virtual reality hypnosis. Written informed consent was obtained from both patients before surgery. A 69-year-old man, with a previous medical history of severe symptomatic aortic valve stenosis (Theta 0.69cm(2), max/mean gradient of 91/58mmHg) sustained a proximal humerus fracture-dislocation and was scheduled to undergo shoulder hemi-arthroplasty. Anesthesia was provided with ultrasound-guided continuous interscalene block at the C5-C6 level (11 mL levobupivacaine 0.5%) combined with a single-shot superficial cervical plexus block (6mL levobupivacaine 0.5%). The second case was a 56-year-old man suffering from rheumatoid arthritis with severe restrictive lung function due to interstitial lung disease and bilateral bronchiectasis. He received a unilateral elbow prosthesis. Continuous infra-clavicular brachial plexus block, performed under ultrasound guidance was provided (20 mL mepivacaine 1.5%). Both patients required prolonged immobilization on the operating table. We used virtual reality hypnosis to induce sedation and improve comfort without using medication. This was provided by headphones and head-mounted goggles, showing computer generated images of underwater scenes (Aqua module, Oncomfort (TM)). Both surgeries were uneventful during which time cardiorespiratory stability was maintained. Patients were comfortable during and satisfied after surgery. No sedative drugs were given before nor during the procedures. Conclusion: Non-pharmacological sedation can be achieved with virtual reality hypnosis. When combined with regional anesthesia, this technique provides satisfactory sedation when pharmacological methods may be hazardous.