is inadequate, and since 60 cmH
O exceeds the mucosal capillary
perfusion pressure, we believe that a pressure range of 20-
O is more sensible. In our clinical practice, we have not
encountered any problems with the lower pressure range.
CONFLICT OF INTEREST
The authors report no conflict of interest.
Ethics approval was granted by the Organizational Research Risk &
Quality Improvement Review Panel of Children’s Hospital Colorado.
This study received no external funding.
Robert H. Friesen
Christian M. Taylor
Robert H. Friesen
Department of Anesthesiology, Children’s Hospital Colorado, University
of Colorado School of Medicine, Aurora, CO, USA
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Augmented reality for intravenous access in an autistic child
with difficult access
Sir—Intravenous (IV) induction is often safer in morbidly obese
children given the increased risk of adverse respiratory events
during mask induction.
However, preinduction IV access in these
patients is often difficult, which can increase preoperative pain,
stress, and anxiety.
Over the years, several pharmacological and
nonpharmacological techniques have been used as aids to attain
preinduction IV access. Effective nonpharmacologic techniques
include but are not limited to, hypnosis, cognitive behavioral ther-
apy, guided imagery, and distraction.
In this letter, we describe a
novel visual distraction technique, the use of augmented reality
(AR) glasses to reduce anxiety while obtaining preinduction IV
access. Most people are familiar with virtual reality: donning a
headset that goes over the eyes and immerses the wearer senso-
rially in an artificial world.
Augmented reality, on the other hand,
takes visual information and superimposes it on the actual envi-
ronment, for example, creating the image of a Pok
on someone’s lawn.
Informed consent for publication of this case
An anxious, autistic, morbidly obese (BMI 57), 11-year-old child
with multiple poor IV experiences was presented for esophagogas-
troduodenoscopy (EGD). Two novel nonpharmacological techniques
to reduce anxiety were discussed with the patient and the family:
virtual reality (VR) and AR glasses. The child declined the VR glasses
because he wanted to “see what is going on” and opted for AR
glasses as they allowed for partial immersion while still being able to
see his surroundings. Upon wearing the AR glasses, interactive car-
toon holograms, named Ben and Jenny, projected in front of the
patient through a Microsoft HoloLens. The experience was mirrored
onto a tablet that allowed providers to know exactly what was in
the patient’s field of view (Figure 1A). Once the patient said, “IV
Prep”, Ben and Jenny began discussing the IV cannulation process in
an interactive and playful fashion. Aspects such as access sites, indi-
cations, and needle pain reducing tactics were discussed. To enhance
engagement, the child brought his fingers together in front of the
screen to fire virtual paintballs at anything in his vision. At this point,
the IV was performed. Throughout the process, the patient remained
engaged with the glasses while periodically looking at the needle
(Figure 1B). At no point, did the child appear anxious. After success-
ful cannulation, the mother was extremely satisfied, and the child
described the experience as “the best IV I’ve ever gotten”.
This case illustrates successful application of AR glasses in
the perioperative care of a child with autism that refused VR