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INTRODUCTION: The Microsoft HoloLens is a head-mounted mixed reality device, which allows for overlaying hologram-like computer-generated elements onto the real world. This technology can be combined with preprocedural ultrasound during thoracic epidural placement to create a visual of the ideal needle angulation and trajectory in the users' field of view. This could result in a technically easier and potentially safer alternative to traditional blind landmark techniques. METHODS: Patients were randomly assigned to one of two groups: (1) HoloLens-assisted thoracic epidural technique (intervention-group H) or (2) traditional thoracic epidural technique (control-group C). The primary outcome was needling time (defined as skin puncture to insertion of epidural catheter) during the procedure. The secondary outcomes were number of needle punctures, number of needle movements, number of bone contacts, and epidural failure. Procedural pain and recovery room pain levels were also evaluated. RESULTS: Eighty-three patients were included in this study. The primary outcome of procedure time was reduced in the HoloLens group compared with control (4.5 min vs 7.3 min, p=0.02, 95% CI), as was the number of needle movements required (7.2 vs 14.4, p=0.01), respectively. There was no difference in intraprocedure or postprocedure pain, bone contacts, or total number of needle punctures. Three patients in the control group experienced epidural failure versus one patient in the HoloLens group. CONCLUSIONS: This study shows that thoracic epidural placement may be facilitated by using a guidance hologram and may be more technically efficient. TRIAL REGISTRATION NUMBER: NCT04028284.
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Innovation in medical education is not only inevitable but a requirement. Manikin-based simulation is currently the gold standard for supplemental clinical training; however, this modality requires significant equipment and personnel to operate. Virtual reality (VR) is emerging as a new method of delivering medical simulation sessions that requires less infrastructure but also allows for greater accessibility and flexibility. VR has slowly been integrated into the medical curriculum in some hospitals; however, more widespread adoption would transform the delivery of medical education for future clinicians. This tutorial introduces educators to the BUILD REALITY (begin, use, identify, leverage, define, recreate, educate, adapt, look, identify, test, amplify) framework, a series of practical tips for designing and implementing a VR-based medical simulation environment in their curriculum. The suggestions are based on the relevant literature and the authors' personal experience in creating and implementing VR environments for medical trainees. Altogether, this paper provides guidance on conducting a needs assessment, setting objectives, designing a VR environment, and incorporating the session into the broader medical curriculum.
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BACKGROUND: Neuraxial anesthesia is conventionally performed using a landmark-based technique. Preprocedural ultrasound is often used in challenging clinical scenarios to identify an ideal needle path. The procedure is then carried out by the operator recreating the ultrasound needle path from memory. We suggest that a needle guidance system using the Microsoft HoloLens mixed reality headset, which projects a hologram of the ideal needle path, can assist operators in replicating the correct needle angulation and result in fewer needle passes. OBJECTIVE: The objective of the study was to develop software for the mixed reality HoloLens headset, which could be used to augment the performance of neuraxial anesthesia, and establish its face validity in lumbar spine phantom models. METHODS: We developed an ultrasound transducer marker and software for the HoloLens, which registers the position and angulation of the ultrasound transducer during preprocedural scans. Once an image of a clear path from skin to the intrathecal space is acquired, a hologram of the ideal needle path is projected onto the user's visual field. The ultrasound probe is removed while the hologram remains in the correct spatial position to visualize the needle trajectory during the procedure as if conducting real-time ultrasound. User testing was performed using a lumbar spine phantom. RESULTS: Preliminary work demonstrates that novice (2 anesthesia residents) and experienced operators (5 attending anesthesiologists) can rapidly learn to use mixed reality holograms to perform neuraxial anesthesia on lumbar spine phantoms. CONCLUSIONS: Our study shows promising results for performing neuraxial anesthesia in phantoms using the HoloLens. Although this may have wide-ranging implications for image-guided therapies, further study is required to quantify the accuracy and safety benefit of using holographic guidance. TRIAL REGISTRATION: ClinicalTrials.gov NCT04028284; https://clinicaltrials.gov/ct2/show/NCT04028284.
