Automatic Segmentation and Probe Guidance for Real-Time Assistance of Ultrasound-Guided Femoral Nerve Blocks

Current evidence on artificial intelligence in regional anesthesia

The recent advancement in regional anesthesia (RA) has been largely attributed to ultrasound technology. However, the safety and efficiency of ultrasound-guided nerve blocks depend upon the skill and experience of the performer. Even with adequate training, experience, and knowledge, human-related limitations such as fatigue, failure to recognize the correct anatomical structure, and unintentional needle or probe movement can hinder the overall effectiveness of RA. The amalgamation of artificial intelligence (AI) to RA practice has promised to override these human limitations. Machine learning, an integral part of AI can improve its performance through continuous learning and experience, like the human brain. It enables computers to recognize images and patterns specifically useful in anatomic structure identification during the performance of RA. AI can provide real-time guidance to clinicians by highlighting important anatomical structures on ultrasound images, and it can also assist in needle tracking and accurate deposition of local anesthetics. The future of RA with AI integration appears promising, yet obstacles such as device malfunction, data privacy, regulatory barriers, and cost concerns can deter its clinical implementation. The current mini review deliberates the current application, future direction, and barrier to the application of AI in RA practice.

Artificial intelligence for ultrasound scanning in regional anaesthesia: a scoping review of the evidence from multiple disciplines

BACKGROUND

Artificial intelligence (AI) for ultrasound scanning in regional anaesthesia is a rapidly developing interdisciplinary field. There is a risk that work could be undertaken in parallel by different elements of the community but with a lack of knowledge transfer between disciplines, leading to repetition and diverging methodologies. This scoping review aimed to identify and map the available literature on the accuracy and utility of AI systems for ultrasound scanning in regional anaesthesia.

METHODS

A literature search was conducted using Medline, Embase, CINAHL, IEEE Xplore, and ACM Digital Library. Clinical trial registries, a registry of doctoral theses, regulatory authority databases, and websites of learned societies in the field were searched. Online commercial sources were also reviewed.

RESULTS

In total, 13,014 sources were identified; 116 were included for full-text review. A marked change in AI techniques was noted in 2016-17, from which point on the predominant technique used was deep learning. Methods of evaluating accuracy are variable, meaning it is impossible to compare the performance of one model with another. Evaluations of utility are more comparable, but predominantly gained from the simulation setting with limited clinical data on efficacy or safety. Study methodology and reporting lack standardisation.

CONCLUSIONS

There is a lack of structure to the evaluation of accuracy and utility of AI for ultrasound scanning in regional anaesthesia, which hinders rigorous appraisal and clinical uptake. A framework for consistent evaluation is needed to inform model evaluation, allow comparison between approaches/models, and facilitate appropriate clinical adoption.

Machine Vision and Image Analysis in Anesthesia: Narrative Review and Future Prospects

Machine vision describes the use of artificial intelligence to interpret, analyze, and derive predictions from image or video data. Machine vision-based techniques are already in clinical use in radiology, ophthalmology, and dermatology, where some applications currently equal or exceed the performance of specialty physicians in areas of image interpretation. While machine vision in anesthesia has many potential applications, its development remains in its infancy in our specialty. Early research for machine vision in anesthesia has focused on automated recognition of anatomical structures during ultrasound-guided regional anesthesia or line insertion; recognition of the glottic opening and vocal cords during video laryngoscopy; prediction of the difficult airway using facial images; and clinical alerts for endobronchial intubation detected on chest radiograph. Current machine vision applications measuring the distance between endotracheal tube tip and carina have demonstrated noninferior performance compared to board-certified physicians. The performance and potential uses of machine vision for anesthesia will only grow with the advancement of underlying machine vision algorithm technical performance developed outside of medicine, such as convolutional neural networks and transfer learning. This article summarizes recently published works of interest, provides a brief overview of techniques used to create machine vision applications, explains frequently used terms, and discusses challenges the specialty will encounter as we embrace the advantages that this technology may bring to future clinical practice and patient care. As machine vision emerges onto the clinical stage, it is critically important that anesthesiologists are prepared to confidently assess which of these devices are safe, appropriate, and bring added value to patient care.

Assisted probe guidance in cardiac ultrasound: A review

Echocardiography is the most frequently used imaging modality in cardiology. However, its acquisition is affected by inter-observer variability and largely dependent on the operator's experience. In this context, artificial intelligence techniques could reduce these variabilities and provide a user independent system. In recent years, machine learning (ML) algorithms have been used in echocardiography to automate echocardiographic acquisition. This review focuses on the state-of-the-art studies that use ML to automate tasks regarding the acquisition of echocardiograms, including quality assessment (QA), recognition of cardiac views and assisted probe guidance during the scanning process. The results indicate that performance of automated acquisition was overall good, but most studies lack variability in their datasets. From our comprehensive review, we believe automated acquisition has the potential not only to improve accuracy of diagnosis, but also help novice operators build expertise and facilitate point of care healthcare in medically underserved areas.

Artificial intelligence using deep neural network learning for automatic location of the interscalene brachial plexus in ultrasound images

BACKGROUND

Identifying the interscalene brachial plexus can be challenging during ultrasound-guided interscalene block.

OBJECTIVE

We hypothesised that an algorithm based on deep learning could locate the interscalene brachial plexus in ultrasound images better than a nonexpert anaesthesiologist, thus possessing the potential to aid anaesthesiologists.

DESIGN

Observational study.

SETTING

A tertiary hospital in Shanghai, China.

PATIENTS

Patients undergoing elective surgery.

INTERVENTIONS

Ultrasound images at the interscalene level were collected from patients. Two independent image datasets were prepared to train and evaluate the deep learning model. Three senior anaesthesiologists who were experts in regional anaesthesia annotated the images. A deep convolutional neural network was developed, trained and optimised to locate the interscalene brachial plexus in the ultrasound images. Expert annotations on the datasets were regarded as an accurate baseline (ground truth). The test dataset was also annotated by five nonexpert anaesthesiologists.

MAIN OUTCOME MEASURES

The primary outcome of the research was the distance between the lateral midpoints of the nerve sheath contours of the model predictions and ground truth.

RESULTS

The data set was obtained from 1126 patients. The training dataset comprised 11 392 images from 1076 patients. The test dataset constituted 100 images from 50 patients. In the test dataset, the median [IQR] distance between the lateral midpoints of the nerve sheath contours of the model predictions and ground truth was 0.8 [0.4 to 2.9] mm: this was significantly shorter than that between nonexpert predictions and ground truth (3.4 mm [2.1 to 4.5] mm; P < 0.001).

CONCLUSION

The proposed model was able to locate the interscalene brachial plexus in ultrasound images more accurately than nonexperts.

TRIAL REGISTRATION

ClinicalTrials.gov (https://clinicaltrials.gov) identifier: NCT04183972.

Attention-VGG16-UNet: a novel deep learning approach for automatic segmentation of the median nerve in ultrasound images

BACKGROUND

Ultrasonography-an imaging technique that can show the anatomical section of nerves and surrounding tissues-is one of the most effective imaging methods to diagnose nerve diseases. However, segmenting the median nerve in two-dimensional (2D) ultrasound images is challenging due to the tiny and inconspicuous size of the nerve, the low contrast of images, and imaging noise. This study aimed to apply deep learning approaches to improve the accuracy of automatic segmentation of the median nerve in ultrasound images.

METHODS

In this study, we proposed an improved network called VGG16-UNet, which incorporates a contracting path and an expanding path. The contracting path is the VGG16 model with the 3 fully connected layers removed. The architecture of the expanding path resembles the upsampling path of U-Net. Moreover, attention mechanisms or/and residual modules were added to the U-Net and VGG16-UNet, which sequentially obtained Attention-UNet (A-UNet), Summation-UNet (S-UNet), Attention-Summation-UNet (AS-UNet), Attention-VGG16-UNet (A-VGG16-UNet), Summation-VGG16-UNet (S-VGG16-UNet), and Attention-Summation-VGG16-UNet (AS-VGG16-UNet). Each model was trained on the dataset of 910 median nerve images from 19 participants and tested on 207 frames from a new image sequence. The performance of the models was evaluated by metrics including Dice similarity coefficient (Dice), Jaccard similarity coefficient (Jaccard), Precision, and Recall. Based on the best segmentation results, we reconstructed a 3D median nerve image using the volume rendering method in the Visualization Toolkit (VTK) to assist in clinical nerve diagnosis.

RESULTS

The results of paired t-tests showed significant differences (P<0.01) in the metrics' values of different models. It showed that AS-UNet ranked first in U-Net models. The VGG16-UNet and its variants performed better than the corresponding U-Net models. Furthermore, the model's performance with the attention mechanism was superior to that with the residual module either based on U-Net or VGG16-UNet. The A-VGG16-UNet achieved the best performance (Dice =0.904±0.035, Jaccard =0.826±0.057, Precision =0.905±0.061, and Recall =0.909±0.061). Finally, we applied the trained A-VGG16-UNet to segment the median nerve in the image sequence, then reconstructed and visualized the 3D image of the median nerve.

CONCLUSIONS

This study demonstrates that the attention mechanism and residual module improve deep learning models for segmenting ultrasound images. The proposed VGG16-UNet-based models performed better than U-Net-based models. With segmentation, a 3D median nerve image can be reconstructed and can provide a visual reference for nerve diagnosis.

Artificial Intelligence: Innovation to Assist in the Identification of Sono-anatomy for Ultrasound-Guided Regional Anaesthesia

Ultrasound-guided regional anaesthesia (UGRA) involves the targeted deposition of local anaesthesia to inhibit the function of peripheral nerves. Ultrasound allows the visualisation of nerves and the surrounding structures, to guide needle insertion to a perineural or fascial plane end point for injection. However, it is challenging to develop the necessary skills to acquire and interpret optimal ultrasound images. Sound anatomical knowledge is required and human image analysis is fallible, limited by heuristic behaviours and fatigue, while its subjectivity leads to varied interpretation even amongst experts. Therefore, to maximise the potential benefit of ultrasound guidance, innovation in sono-anatomical identification is required.Artificial intelligence (AI) is rapidly infiltrating many aspects of everyday life. Advances related to medicine have been slower, in part because of the regulatory approval process needing to thoroughly evaluate the risk-benefit ratio of new devices. One area of AI to show significant promise is computer vision (a branch of AI dealing with how computers interpret the visual world), which is particularly relevant to medical image interpretation. AI includes the subfields of machine learning and deep learning, techniques used to interpret or label images. Deep learning systems may hold potential to support ultrasound image interpretation in UGRA but must be trained and validated on data prior to clinical use.Review of the current UGRA literature compares the success and generalisability of deep learning and non-deep learning approaches to image segmentation and explains how computers are able to track structures such as nerves through image frames. We conclude this review with a case study from industry (ScanNav Anatomy Peripheral Nerve Block; Intelligent Ultrasound Limited). This includes a more detailed discussion of the AI approach involved in this system and reviews current evidence of the system performance.The authors discuss how this technology may be best used to assist anaesthetists and what effects this may have on the future of learning and practice of UGRA. Finally, we discuss possible avenues for AI within UGRA and the associated implications.

Transforming obstetric ultrasound into data science using eye tracking, voice recording, transducer motion and ultrasound video

Ultrasound is the primary modality for obstetric imaging and is highly sonographer dependent. Long training period, insufficient recruitment and poor retention of sonographers are among the global challenges in the expansion of ultrasound use. For the past several decades, technical advancements in clinical obstetric ultrasound scanning have largely concerned improving image quality and processing speed. By contrast, sonographers have been acquiring ultrasound images in a similar fashion for several decades. The PULSE (Perception Ultrasound by Learning Sonographer Experience) project is an interdisciplinary multi-modal imaging study aiming to offer clinical sonography insights and transform the process of obstetric ultrasound acquisition and image analysis by applying deep learning to large-scale multi-modal clinical data. A key novelty of the study is that we record full-length ultrasound video with concurrent tracking of the sonographer's eyes, voice and the transducer while performing routine obstetric scans on pregnant women. We provide a detailed description of the novel acquisition system and illustrate how our data can be used to describe clinical ultrasound. Being able to measure different sonographer actions or model tasks will lead to a better understanding of several topics including how to effectively train new sonographers, monitor the learning progress, and enhance the scanning workflow of experts.

A real-time anatomy ıdentification via tool based on artificial ıntelligence for ultrasound-guided peripheral nerve block procedures: an accuracy study

We aimed to assess the accuracy of an artificial intelligence (AI)-based real-time anatomy identification software specifically developed to ease image interpretation intended for ultrasound-guided peripheral nerve block (UGPNB). Forty healthy participants (20 women, 20 men) were enrolled to perform interscalene, supraclavicular, infraclavicular, and transversus abdominis plane (TAP) blocks under ultrasound guidance using AI software by anesthesiology trainees. During block practice by a trainee, once the software indicates 100% scan success of each block associated anatomic landmarks, both raw and labeled ultrasound images were saved, assessed, and validated using a 5-point scale by expert validators. When trainees reached 100% scan success, accuracy scores of the validators were noted. Correlation analysis was used whether the relationship (r) according to demographics (gender, age, and body mass index: BMI) and block type exist. The BMI (kg/m²) and age (year) of participants were 22.2 ± 3 and 32.2 ± 5.25, respectively. Assessment scores of validators for all blocks were similar in male and female individuals. Mean assessment scores of validators were not significantly different according to age and BMI except for TAP block, which was inversely correlated with age and BMI (p = 0.01). AI technology can successfully interpret anatomical structures in real-time sonography while assisting young anesthesiologists during UGPNB practice.

Highlighting nerves and blood vessels for ultrasound-guided axillary nerve block procedures using neural networks

Ultrasound images acquired during axillary nerve block procedures can be difficult to interpret. Highlighting the important structures, such as nerves and blood vessels, may be useful for the training of inexperienced users. A deep convolutional neural network is used to identify the musculocutaneous, median, ulnar, and radial nerves, as well as the blood vessels in ultrasound images. A dataset of 49 subjects is collected and used for training and evaluation of the neural network. Several image augmentations, such as rotation, elastic deformation, shadows, and horizontal flipping, are tested. The neural network is evaluated using cross validation. The results showed that the blood vessels were the easiest to detect with a precision and recall above 0.8. Among the nerves, the median and ulnar nerves were the easiest to detect with an F -score of 0.73 and 0.62, respectively. The radial nerve was the hardest to detect with an F -score of 0.39. Image augmentations proved effective, increasing F -score by as much as 0.13. A Wilcoxon signed-rank test showed that the improvement from rotation, shadow, and elastic deformation augmentations were significant and the combination of all augmentations gave the best result. The results are promising; however, there is more work to be done, as the precision and recall are still too low. A larger dataset is most likely needed to improve accuracy, in combination with anatomical and temporal models.