First-in-human evaluation of a hand-held automated venipuncture device for rapid venous blood draws.

Obtaining venous access for blood sampling or intravenous (IV) fluid delivery is an essential first step in patient care. However, success rates rely heavily on clinician experience and patient physiology. Difficulties in obtaining venous access result in missed sticks and injury to patients, and typically require alternative access pathways and additional personnel that lengthen procedure times, thereby creating unnecessary costs to healthcare facilities. Here, we present the first-in-human assessment of an automated robotic venipuncture device designed to safely perform blood draws on peripheral forearm veins. The device combines ultrasound imaging and miniaturized robotics to identify suitable vessels for cannulation and robotically guide an attached needle toward the lumen center. The device demonstrated results comparable to or exceeding that of clinical standards, with a success rate of 87% on all participants (n = 31), a 97% success rate on nondifficult venous access participants (n = 25), and an average procedure time of 93 ± 30 s (n = 31). In the future, this device can be extended to other areas of vascular access such as IV catheterization, central venous access, dialysis, and arterial line placement.

Design and Evaluation of a Robotic Device for Automated Tail Vein Cannulations in Rodent Models.

Preclinical testing in rodent models is a ubiquitous part of modern biomedical research and commonly involves accessing the venous bloodstream for blood sampling and drug delivery. Manual tail vein cannulation is a time-consuming process and requires significant skill and training, particularly since improperly inserted needles can affect the experimental results and study outcomes. In this paper, we present a miniaturized, robotic medical device for automated, image-guided tail vein cannulations in rodent models. The device is composed of an actuated three degrees-of-freedom (DOFs) needle manipulator, three-dimensional (3D) near-infrared (NIR) stereo cameras, and an animal holding platform. Evaluating the system through a series of workspace simulations and free-space positioning tests, the device exhibited a sufficient work volume for the needle insertion task and submillimeter accuracy over the calibration targets. The results indicate that the device is capable of cannulating tail veins in rodent models as small as 0.3 mm in diameter, the smallest diameter vein required to target.

Adaptive Kinematic Control of a Robotic Venipuncture Device Based on Stereo Vision, Ultrasound, and Force Guidance.

Robotic systems have slowly entered the realm of modern medicine; however, outside the operating room, medical robotics has yet to be translated to more routine interventions such as blood sampling or intravenous fluid delivery. In this paper, we present a medical robot that safely and rapidly cannulates peripheral blood vessels-a procedure commonly known as venipuncture. The device uses near-infrared and ultrasound imaging to scan and select suitable injection sites, and a 9-DOF robot to insert the needle into the center of the vessel based on image and force guidance. We first present the system design and visual servoing scheme of the latest generation robot, and then evaluate the performance of the device through workspace simulations and free-space positioning tests. Finally, we perform a series of motion tracking experiments using stereo vision, ultrasound, and force sensing to guide the position and orientation of the needle tip. Positioning experiments indicate sub-millimeter accuracy and repeatability over the operating workspace of the system, while tracking studies demonstrate real-time needle servoing in response to moving targets. Lastly, robotic phantom cannulations demonstrate the use of multiple system states to confirm that the needle has reached the center of the vessel.

3D Near Infrared and Ultrasound Imaging of Peripheral Blood Vessels for Real-Time Localization and Needle Guidance.

This paper presents a portable imaging device designed to detect peripheral blood vessels for cannula insertion that are otherwise difficult to visualize beneath the skin. The device combines near infrared stereo vision, ultrasound, and real-time image analysis to map the 3D structure of subcutaneous vessels. We show that the device can identify adult forearm vessels and be used to guide manual insertions in tissue phantoms with increased first-stick accuracy compared to unassisted cannulation. We also demonstrate that the system may be coupled with a robotic manipulator to perform automated, image-guided venipuncture.

Multilayered tissue mimicking skin and vessel phantoms with tunable mechanical, optical, and acoustic properties.

PURPOSE: This paper describes the design, fabrication, and characterization of multilayered tissue mimicking skin and vessel phantoms with tunable mechanical, optical, and acoustic properties. The phantoms comprise epidermis, dermis, and hypodermis skin layers, blood vessels, and blood mimicking fluid. Each tissue component may be individually tailored to a range of physiological and demographic conditions. METHODS: The skin layers were constructed from varying concentrations of gelatin and agar. Synthetic melanin, India ink, absorbing dyes, and Intralipid were added to provide optical absorption and scattering in the skin layers. Bovine serum albumin was used to increase acoustic attenuation, and 40 µm diameter silica microspheres were used to induce acoustic backscatter. Phantom vessels consisting of thin-walled polydimethylsiloxane tubing were embedded at depths of 2-6 mm beneath the skin, and blood mimicking fluid was passed through the vessels. The phantoms were characterized through uniaxial compression and tension experiments, rheological frequency sweep studies, diffuse reflectance spectroscopy, and ultrasonic pulse-echo measurements. Results were then compared to in vivo and ex vivo literature data. RESULTS: The elastic and dynamic shear behavior of the phantom skin layers and vessel wall closely approximated the behavior of porcine skin tissues and human vessels. Similarly, the optical properties of the phantom tissue components in the wavelength range of 400-1100 nm, as well as the acoustic properties in the frequency range of 2-9 MHz, were comparable to human tissue data. Normalized root mean square percent errors between the phantom results and the literature reference values ranged from 1.06% to 9.82%, which for many measurements were less than the sample variability. Finally, the mechanical and imaging characteristics of the phantoms were found to remain stable after 30 days of storage at 21 °C. CONCLUSIONS: The phantoms described in this work simulate the mechanical, optical, and acoustic properties of human skin tissues, vessel tissue, and blood. In this way, the phantoms are uniquely suited to serve as test models for multimodal imaging techniques and image-guided interventions.

System Design and Development of a Robotic Device for Automated Venipuncture and Diagnostic Blood Cell Analysis.

Diagnostic blood testing is the most prevalent medical procedure performed in the world and forms the cornerstone of modern health care delivery. Yet blood tests are still predominantly carried out in centralized labs using large-volume samples acquired by manual venipuncture, and no end-to-end solution from blood draw to sample analysis exists today. Our group is developing a platform device that merges robotic phlebotomy with automated diagnostics to rapidly deliver patient information at the site of the blood draw. The system couples an image-guided venipuncture robot, designed to address the challenges of routine venous access, with a centrifuge-based blood analyzer to obtain quantitative measurements of hematology. In this paper, we first present the system design and architecture of the integrated device. We then perform a series of in vitro experiments to evaluate the cannulation accuracy of the system on blood vessel phantoms. Next, we assess the effects of vessel diameter, needle gauge, flow rate, and viscosity on the rate of sample collection. Finally, we demonstrate proof-of-concept of a white cell assay on the blood analyzer using in vitro human samples spiked with fluorescently labeled microbeads.

Differential Leukocyte Counting via Fluorescent Detection and Image Processing on a Centrifugal Microfluidic Platform.

Centrifugal microfluidics has received much attention in the last decade for the automation of blood testing at the point-of-care, specifically for the detection of chemistries, proteins, and nucleic acids. However, the detection of common blood cells on-disc, particularly leukocytes, remains a challenge. In this paper, we present two analytical methods for enumerating leukocytes on a centrifugal platform using a custom-built fluorescent microscope, acridine orange nuclear staining, and image processing techniques. In the first method, cell analysis is performed in glass capillary tubes; in the second, acrylic chips are used. A bulk-cell analysis approach is implemented in both cases where the pixel areas of fractionated lymphocyte/monocyte and granulocyte layers are correlated with cell counts. Generating standard curves using porcine blood sample controls, we observed strong linear fits to measured cell counts using both methods. Analyzing the pixel intensities of the fluorescing white cell region, we are able to differentiate lymphocytes from monocytes via pixel clustering, demonstrating the capacity to perform a 3-part differential. Finally, a discussion of pros and cons of the bulk-cell analysis approach concludes the paper.

The System Design and Evaluation of a 7-DOF Image-Guided Venipuncture Robot.

Accessing the venous bloodstream to deliver fluids or obtain a blood sample is the most common clinical routine practiced in the U.S. Practitioners continue to rely on manual venipuncture techniques, but success rates are heavily dependent on clinician skill and patient physiology. In the U.S., failure rates can be as high as 50% in difficult patients, making venipuncture the leading cause of medical injury. To improve the rate of first-stick success, we have developed a portable autonomous venipuncture device that robotically servos a needle into a suitable vein under image guidance. The device operates in real time, combining near-infrared and ultra-sound imaging, image analysis, and a 7-degree-of-freedom (DOF) robotic system to perform the venipuncture. The robot consists of a 3-DOF gantry to image the patient's peripheral forearm veins and a miniaturized 4-DOF serial arm to guide the cannula into the selected vein under closed-loop control. In this paper, we present the system architecture of the robot and evaluate the accuracy and precision through tracking, free-space positioning, and in vitro phantom cannulation experiments. The results demonstrate sub-millimeter accuracy throughout the operating workspace of the manipulator and a high rate of success when cannulating phantom veins in a skin-mimicking tissue model.

Real-time Needle Steering in Response to Rolling Vein Deformation by a 9-DOF Image-Guided Autonomous Venipuncture Robot.

Venipuncture is the most common invasive medical procedure performed in the United States and the number one cause of hospital injury. Failure rates are particularly high in pediatric and elderly patients, whose veins tend to deform, move, or roll as the needle is introduced. To improve venipuncture accuracy in challenging patient populations, we have developed a portable device that autonomously servos a needle into a suitable vein under image guidance. The device operates in real time, combining near-infrared and ultrasound imaging, computer vision software, and a 9 degrees-of-freedom robot that servos the needle. In this paper, we present the kinematic and mechanical design of the latest generation robot. We then investigate in silico and in vitro the mechanics of vessel rolling and deformation in response to needle insertions performed by the robot. Finally, we demonstrate how the robot can make real-time adjustments under ultrasound image guidance to compensate for subtle vessel motions during venipuncture.

Automated image analysis method for detecting and quantifying macrovesicular steatosis in hematoxylin and eosin-stained histology images of human livers.

Large-droplet macrovesicular steatosis (ld-MaS) in more than 30% of liver graft hepatocytes is a major risk factor for liver transplantation. An accurate assessment of the ld-MaS percentage is crucial for determining liver graft transplantability, which is currently based on pathologists' evaluations of hematoxylin and eosin (H&E)-stained liver histology specimens, with the predominant criteria being the relative size of the lipid droplets (LDs) and their propensity to displace a hepatocyte's nucleus to the cell periphery. Automated image analysis systems aimed at objectively and reproducibly quantifying ld-MaS do not accurately differentiate large LDs from small-droplet macrovesicular steatosis and do not take into account LD-mediated nuclear displacement; this leads to a poor correlation with pathologists' assessments. Here we present an improved image analysis method that incorporates nuclear displacement as a key image feature for segmenting and classifying ld-MaS from H&E-stained liver histology slides. 52,000 LDs in 54 digital images from 9 patients were analyzed, and the performance of the proposed method was compared against the performance of current image analysis methods and the ld-MaS percentage evaluations of 2 trained pathologists from different centers. We show that combining nuclear displacement and LD size information significantly improves the separation between large and small macrovesicular LDs (specificity = 93.7%, sensitivity = 99.3%) and the correlation with pathologists' ld-MaS percentage assessments (linear regression coefficient of determination = 0.97). This performance vastly exceeds that of other automated image analyzers, which typically underestimate or overestimate pathologists' ld-MaS scores. This work demonstrates the potential of automated ld-MaS analysis in monitoring the steatotic state of livers. The image analysis principles demonstrated here may help to standardize ld-MaS scores among centers and ultimately help in the process of determining liver graft transplantability.

Anti-inflammatory/Anti-oxidative stress activities and differential regulation of Nrf2-mediated genes by non-polar fractions of tea Chrysanthemum zawadskii and licorice Glycyrrhiza uralensis.

Accumulating evidence from epidemiological studies indicates that chronic inflammation and oxidative stress play critical roles in neoplastic development. The aim of this study was to investigate the anti-inflammatory, anti-oxidative stress activities, and differential regulation of Nrf2-mediated genes by tea Chrysanthemum zawadskii (CZ) and licorice Glycyrrhiza uralensis (LE) extracts. The anti-inflammatory and anti-oxidative stress activities of hexane/ethanol extracts of CZ and LE were investigated using in vitro and in vivo approaches, including quantitative real-time PCR (qPCR) and microarray. Additionally, the role of the transcriptional factor Nrf2 (nuclear erythroid-related factor 2) signaling pathways was examined. Our results show that CZ and LE extracts exhibited potent anti-inflammatory activities by suppressing the mRNA and protein expression levels of pro-inflammatory biomarkers IL-1ß, IL-6, COX-2 and iNOS in LPS-stimulated murine RAW 264.7 macrophage cells. CZ and LE also significantly suppressed the NO production of LPS-stimulated RAW 264.7 cells. Additionally, CZ and LE suppressed the NF-κB luciferase activity in human HT-29 colon cancer cells. Both extracts also showed strong Nrf2-mediated antioxidant/Phase II detoxifying enzymes induction. CZ and LE induced NQO1, Nrf2, and UGT and antioxidant response element (ARE)-luciferase activity in human hepatoma HepG2 C8 cells. Using Nrf2 knockout [Nrf2 (-/-)] and Nrf2 wild-type (+/+) mice, LE and CZ showed Nrf2-dependent transactivation of Nrf2-mediated antioxidant and phase II detoxifying genes. In summary, CZ and LE possess strong inhibitory effects against NF-κB-mediated inflammatory as well as strong activation of the Nrf2-ARE-anti-oxidative stress signaling pathways, which would contribute to their overall health promoting pharmacological effects against diseases including cancer.