3DUI Electronic Syringe for Neonate Central Venous Access Procedure Simulation
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The central venous access is a highly complex medical procedure, which consists of accessing a central vein (e.g., femoral vein, jugular vein or the umbilicus) to deliver different drugs, anesthesia, fluids or treatments to the patient. This procedure requires a high degree of expertise and its malpractice can result in severe consequences for the patient leading to possible pneumothorax, hemothorax and even death, among many other health risks. In neonates, the procedure is even more challenging because of the anatomical features. The lack of training tools requires trainees to transfer knowledge from adult venous access to the neonate; therefore, it is highly necessary to create training tools for specialists. In this paper, the development of an interactive simulation system for practicing the needle insertion in the internal jugular vein in neonates is presented. A real model of a syringe coupled with inertial sensors was built to permit the interaction between the user and a neonate virtual model displayed on a touch screen. This system has been evaluated by users, who expressed great potential in this interactive simulation for training.
KeywordsCentral venous access Haptic Syringe Inertial measurement unit
The central venous access (CVA) is an invasive medical procedure that allows accessing the big circulatory vessels (e.g., jugular, subclavian or femoral vein) to provide drugs, anesthesia, fluids or treatments to the patient in a critical condition . It requires skilled specialists to successfully perform the technique and avoid any complications that may compromise the patients life [17, 20]. In neonates, the procedure is even more challenging because of the size, gaps between organs, tissues and their mechanical properties. It has been shown that skills related to this procedure are improved with the use of training simulators [4, 16, 18, 21], where virtual or real manikins are used to represent patient anatomy and vital functions in a controlled environment [8, 15, 27]. There are several CVA simulators for 5+ years old patients (CVC Insertion Simulator II , Gen II Ultrasound Central Line Training Model , Internal Jugular Central Line Ultrasound Manikin , VascularAccessChild Training System ) designed for jugular, femoral and subclavian vein access, while CVA simulators for neonates are only focused on umbilicus, femoral and peripheral venous access and intraosseous access (Simbaby , SimNewB , BabySIM , Newborn PEDI Simulator ). However, neonatal CVA simulators for jugular and subclavian veins are scarce, lack to be remedied since the cannulation of these vessels is common in medical practice [25, 26] and its realization requires greater skills obtained through practice .
An interactive simulation system for practicing the needle insertion in the access of the internal jugular vein in neonates is proposed. The system has a physical syringe coupled with inertial sensors and a virtual model of the neonatal patient displayed on a touch screen of a tablet device. During the simulation, the system generates a visual feedback for successful access to the internal jugular vein, or a failed attempt when the carotid artery is accessed. Both are closely spaced vessels. The response is based on a linear estimation of the intersection between the needle tip and the vessel, considering the insertion point on the patient skin, the angle chosen by the user and the position, orientation, and diameter of the target vessels. This paper is divided as follows: in Sect. 2 the medical procedure and the design of the proposed simulation system are described. In Sect. 3 the results of the user experience are presented. Finally, conclusions and future work are presented in Sect. 4.
2 3DUI Syringe Development
2.1 System Architecture
Using the needle insertion procedure in jugular CVA as a reference, we define the 3DUI inputs and outputs so our solution represents life-like interactions with a real syringe. For the proposed system a physical model of the syringe was built, coupled with inertial sensors to estimate its orientation, interacting with a virtual model of a neonate displayed on a touchscreen of a mobile device (tablet). During the procedure, the user can freely handle the syringe to select an access point on the touchscreen where the neonate is displayed. When the tip of the syringe touches the screen, the system estimates if the needle is accessing the internal jugular vein or the carotid artery, performing an extension of the needle into the neonate, gradually, to a defined length, continuously evaluating the possible collision of the needle tip with the vessels represented by cylindrical geometric shapes. A description of the proposed system is presented in Fig. 2.
The system requires an initial calibration of the measures taken by the magnetometer and also to align the framework of sensors with the reference frame of the virtual model. The calibration of the magnetometer consists in centering the data regarding the origin, finding maximum and minimum values of each component and normalize them, as proposed by . On the other hand, to align the reference systems of the syringe and mobile device, they must be placed on a flat surface by making that the z-axis of the two coordinate systems points to the normal direction of the surface. Then, the central axis of the syringe is aligned with the x-axis of the virtual model that is parallel to one side of the mobile device.
The virtual environment is composed by a 3D model considering the basic anatomical features described in anatomy books of a term neonate. This model is oriented in the Trendelenburg position with \(15^o\) of inclination which is the recommended for the jugular central venous access procedure. The software was built with Android Studio  using libgdx . For the implementation of the syringe, it was used an Arduino Mini Pro , a 9-DOF inertial measurement unit MPU-9150  which encapsulates an accelerometer, a gyroscope and a magnetometer, a Bluetooth interface for wireless transmission between sensors and the mobile device. This application was implemented on a Samsung Galaxy Note Tablet 8.0 as presented in Fig. 5.
The proposed system includes a user interface to manage different options in the virtual environment. The user has the possibility to adjust the camera in order to change the perspective view of the model with some hand gestures that enable to rotate the model, to approach or to take a distance from it. During the procedure, the user can freely manipulate the syringe to select an access point from the images of the neonate. There is a function that blocks the movement of the camera to help to find the point for performing the procedure.
3.1 User Experience
The visual representation of the neonate is realistic, however, it is important a further enhancement of anatomical landmarks such as the collarbone and nipple, which are key benchmarks for the procedure.
The syringe allows adequate control of the position and orientation at the time of the puncture.
Although the system allows the viewer to manipulate the virtual environment by changing the position of observation of the neonate, it is sufficient that the system allows a small lateral movements around it, as well as zoom in and out of the region of interest.
Within additional observations made by the users are: allowing a three-dimensional view of the virtual environment, for example by defining different views of the same scene on the screen to better identify the position of the observer with respect to the neonate; and to make known the bevel of the needle tip, since its orientation is important for access.
4 Conclusions and Discussion
An interactive simulation system for training puncture in the access of the internal jugular vein was developed. The system is an innovative tool that can complement traditional learning based on the information presented in books and videos, allowing the user to interact with the virtual anatomy and performing the puncture in different manners.
The system can be extended to simulate vital signs, breathing movements and sounds in the environment, under normal conditions and possible complications.
Force feedback is the next step. Using a vibrotactile actuator inside the syringe would be ideal for such applications to represent the rupture of the skin and vessels. This system can be complemented to perform the complete procedure step by step.
This project was supported by the Research Division of Nueva Granada Mil. University through grant IMP ING 1776.
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