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October 24, 2017
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Visual Augmentation Improves Supraclavicular Access to the Subclavian Vein in a Mixed Reality Simulator
Joshua W. Sappenfield, M.D., Lou Ann Cooper, Ph.D., David Lizdas, B.S., Albert R. Robinson, M.D., Samsun Lampotang, Ph.D.
University of Florida, Gainesville, Florida, United States
Disclosures: J.W. Sappenfield: None. L. Cooper: None. D. Lizdas: None. A.R. Robinson: None. S. Lampotang: None.
BACKGROUND: We investigated whether visual augmentation (real-time, color, 3D visualization) of a mixed reality procedural simulator for central venous access (CVA) improved performance during training in the supraclavicular approach to the subclavian vein (ca 1965) that is not as widely known or used as the infraclavicular route. The simulator is a turnkey, compact, robust simulator with 3D visualization that enhances learning,1 (b) allows clinicians more familiar with ultrasound (US)-guided internal jugular (IJ) CVA to acquire and maintain skills

with the generally unfamiliar infraclavicular subclavian venous access route, and (c) provides a simulator to evaluate the alternative supraclavicular approach to the subclavian vein (e.g., during chest compressions). The CVA simulator evaluated in this current study includes simulated US imaging that was not yet available in a prior version.1

METHODS: To train anesthesiology residents to access central veins, we created a turnkey, mixed reality simulator with emulated US imaging using an anatomically authentic, 3D-printed, physical mannequin based on a computed tomography scan of an actual human. The simulator has a corresponding 3D virtual model of the neck and upper chest anatomy. Hand-held instruments such as a needle, a US probe, and a virtual camera controller are directly manipulated by the trainee and tracked with sub-millimeter resolution via miniature, 6 degrees of freedom magnetic sensors.

After IRB approval, 69 anesthesiology residents and faculty were enrolled and received scripted instructions on performing supraclavicular subclavian venous access. The volunteers were randomized into two cohorts. Group RTV used real-time visualization concurrently with trial 1, but not during trial 2. Group DV (delayed visualization) did not use real-time visualization concurrently with trials 1 or 2. However, after trial 2, Group DV watched a 3D visualization playback of trial 2 prior to performing trial 3 without visualization. An automated scoring system based on time, success, and errors/complications generated subject scores. Nonparametric statistical methods were used to compare the scores between subsequent trials, differences between groups (RTV vs. DV), and improvement in scores between trials within groups

RESULTS: The RTV group had significantly better median scores than the DV group prior to receiving visualization in both trial 1 (P = 0.01) and trial 2 (P = 0.007). In the DV group, delayed visualization of performance on trial 2 prior to trial 3 resulted in a significantly improved median score from trial 1 to trial 3 (P = 0.0007). There was no significant difference in median scores (P = 0.13) between groups for the last trial (RTV2 vs. DV3). Participants reported a significant improvement in confidence in performing supraclavicular access to the subclavian vein.

CONCLUSIONS: Visual augmentation (3D visualization) in the mixed reality simulator, whether used in real time or in delayed playback mode, improved performance during supraclavicular access to the subclavian vein. Training with the mixed reality simulator improved participant confidence in performing an unfamiliar technique. Supraclavicular access to the subclavian vein appears to be a straightforward technique to learn.


1. Robinson AR, Gravenstein N, Cooper LA, Lizdas D, Luria I, Lampotang S. Simul Healthc 2014;9:56-64.
Figure 1

Copyright © 2017 American Society of Anesthesiologists