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1 Introduction
1.1 The Need for Vein Contrast Enhancement
Major trauma and blood loss, cardiac arrest, dehydration,
deep shock, and other medical emergencies necessitate
rapid, reliable access to a patients bloodstream to administer drugs and fluids. In the prehospital emergency environment, an infusion line placed in an arm vein is the standard route for obtaining this access. Worldwide, 10% of
attempts at establishing an intravenous IV line, or more
than one million per year, fail. Although the average time
for achieving IV access can be as little as 1.5 min, it ranges
to more than 10.1 During emergencies outside the hospital
setting, paramedics often have to work in very difficult settings, frequently making it impossible to get rapid IV access. A study conducted in Canada reports that paramedics
had an 84% overall success rate at establishing IV lines in
the field in children 18 years old and younger, but only had
a 49% success rate at establishing IV lines in children
younger than 6 years old. Criteria for IV line placement
were determined retrospectively, and for this subgroup of
children only 43% of those younger than 6 years old had an
IV line placed successfully.2 In a study conducted on children younger than four years old presented in cardiac arrest
to a hospital emergency room, the success rate at establishing peripheral IV lines was only 17%, with the success
rates for central venous catheterization, surgical vein cutdown, and intraosseous infusion averaging around 80%.3
For adult inpatient phlebotomy procedures the success rates
are much higher, as few as 2% of all attempted venipunctures being unsuccessful.4 For adult outpatient phlebotomy
the failure rate is reported to be as low as 0.05%.5
If vascular access is accomplished within the first few
minutes of resuscitation, the patient is more likely to
survive.6,7 The quickest and easiest IV access is known to
be through a peripheral venous catheter, and although the
use of modern catheter sets, tourniquets, heat lamps, and
transillumination devices8 has made peripheral IV access
easier than it once was, there are still some emergency pa0091-3286/2005/$22.00 2005 SPIE
Optical Engineering
Fig. 1 The prototype vein contrast enhancer VCE system. A commercial XGA-resolution LCD projector has been extensively modified to produce a 64 48 mm vein image on a subjects arm. The
projector, the infrared light source, the CCD TV camera, and the hot
mirror are all mounted on precision mechanical stages to allow precise alignment. The internal structure of the projector had to be significantly stiffened in order to ensure that the alignment accuracy
would be maintained when the VCE system was tilted from horizontal to vertical.
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Usual no. of
venipuncture
attempts
Contribution
to
score
Somewhat difficult
2 or 3
Difficult
Many
Easy
No. of observations
Patient data
Previous
venipuncture
history score
x-y table. The x axis of the x-y table translated the projector
image in the x direction, and the y axis adjusted the projector lens to screen distance. A Sentech STC-1000 CCD camera with a 35-mm f / 1.9 Schneider Xenoplan lens was
mounted on two Newport Corporation GON65 Series goniometers. The upper goniometer rotated the camera optical
axis in the y direction, and the lower goniometer rotated the
camera image about its optical axis. The camera-andgoniometer assembly was mounted on a Newport Corporation ULTRAlign model 461-Z-M micrometer-adjusted
linear z-axis slide that translated the camera image in the
vertical direction. The x-y table and the linear z-axis slide,
holding the camera and the projector, respectively, were
mounted on a 1.27-cm-thick, 30.5 45.7-cm aluminum
platform so that the projector and camera were mounted at
right angles to each other and with their optical axes crossing at a point 92.8 mm in front of the thin-lens-equivalent
position of both lenses. A 14.3 10.2-cm, 3-mm-thick hot
mirror with a 45-deg cutoff at 650 nm was mounted on a
Newport Corporation model 36 micrometer-adjustable tilt
and rotation platform with a rotation range of 2.5 deg.
The tilt-and-rotation platform was positioned in front of the
camera and the projector with both the projector optical
axis and the camera optical axis passing through the center
of the front surface of the hot mirror at a 45-deg angle. All
the micrometers were model SM-13 micrometers; they had
0.5-mm-pitch 50.8 TPI threads and read directly in units
of 10 m the finest tick marks, with vernier readings of
1 m. The resulting translation sensitivities for both the
camera and the projector were therefore the same as the
sensitivity of the SM-13 micrometers, while the angular
sensitivities using the vernier readings were 2 arcsec for the
mirror rotation, 4.1 arcsec for the camera y axis, and 2.9
arcsec for the image rotation about its axis. Using the direct
readout, the angular sensitivities were about ten times
poorer. One hundred ELD-740-524 infrared LEDs from
Roithner Lasertechnik, mounted symmetrically around the
camera body, illuminated the field of view. The light emitted by the LEDs was diffused by two LSD20PC10 F10
10/ PSA diffusers from the Physical Optics Corporation,
spaced 75 mm apart to make the illumination very uniform.
The infrared illumination was linearly polarized by a VPGS-12U polarizer from Visual Pursuits, Inc., designed for
polarizing visible light. The light entering the camera lens
was cross-polarized using the same polarizer turned at 90
deg to the LED polarizer. The cross-polarization removed
glare from the camera images.
Optical Engineering
Amount of
subcutaneous fat
Darkness of skin
pigmentation
Age
Phlebotomists
ability to feel vein
Subject score
Vein
poorly
seen
Vein
not
seen
21
20
28
Small
45
Medium
32
Large
41
Light
31
Medium
13
Dark
79
02
34
36
18
7+
71
70
29
123
13
10
Cannot feel
Total subjects
Vein
easily
seen
146
3 Optical Design
The 1 / 3-in. CCD chip in the Sentech camera has 7.4
7.4-m pixels. Since the camera has 640 480 pixels,
the active area of the CCD chip is 4.74 3.55 mm. The
0.7-in. LCD chip in the Infocus projector has 13.89
13.89-m pixels. Since the projector has 1024
768 pixels, the active area of the LCD chip is 14.22
10.67 mm. A 35-mm-focal-length lens is used with the
camera, while a 90-mm-focal-length lens is used with the
projector. The desired field of view of the camera on the
subjects arm is 64 48 mm for a spatial resolution of 0.1
mm. Hence, the demagnification factor of the camera lens
must be 13.51, and the lens-to-arm distance must be 508
mm. For the camera field and the projector image to overlie
correctly over the depth of focus of the camera lens of
about 25.4 mm, the projector lens must also be 508 mm
from the arm. Then the desired 64 48-mm projected image must come from 992 744 pixels on the LCD chip. It
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Fig. 3 Top view a and side view b drawings of the prototype VCE
system, showing the precision mechanical stages used to align the
LCD projector with the CCD TV camera. Each adjustment was
made with a micrometer screw with enough precision to align the
projector with the camera to fractional pixel accuracy.
Fig. 2 VCE images of the right hand a and the left hand b of an
11-year-old African American male. The phlebotomist could not feel
any veins in his right hand, and therefore accessed a vein in the left
hand. The VCE clearly visualizes veins in both hands.
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Fig. 4 Adaptive unsharp-masking edge enhancement algorithm. a shows an acquired VGA image of
a superficial vein on the anterior forearm of a 22-year-old female subject, obtained with 760-nm
linearly polarized near-infrared LED illumination. The CCD TV camera has a crossed Polaroid filter
and an infrared transmitting filter that removes light of wavelength shorter than 650 nm. The result of
the adaptive edge enhancement algorithm is shown in b. c shows the enhanced vein image with a
black line to show the column of the image the intensities of which are displayed in d. The right traces
in d are the intensity trace from the original image in a jagged line and the smoothed version of
this intensity trace smooth line. The middle trace is the difference between the original and smoothed
traces. The left trace is the adaptively edge-enhanced trace. e is a photograph taken with a conventional digital camera in visible room illumination. Notice that the vein shown in a is almost invisible in
e. In fact, with the naked eye, this vein is invisible. f is a photograph with the same digital camera
of the same arm with the vein contrast enhancer enhancing the vein. The image in b has been
projected onto the arm in exact alignment with the subjects anatomy.
Automatic Alignment
Software was also used to ensure that the vein image was
projected directly on top of the actual veins themselves.
The projector light was colored green with a green filter to
simulate the green LED illuminator and digital light processing DLP display chip that will be used for projecting
in later versions of the VCE, and was directed at a fluorescent screen, which converted the green light to deep red
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on a computer monitor and repeated the measurements every 7 s to allow the effects of translating or rotating the
optical axes to be observed continually. If the projector
image and the camera image overlay exactly at the focal
distance, the average difference between the x and y positions of the points in the projected and captured images
would be zero, and there would be no detectable rotation
angle between the two images. If the prototype is aligned,
the average difference and the rotation angle should remain
zero as the screen is moved back and forth between the two
positions 25.4 mm closer to or further away from the focus
distance. Any measured average difference between the
points would be caused by the optical axes not being parallel. Each translation and rotation stage was calibrated by
first aligning the prototype manually, and then measuring
the average position of the four dots in the test pattern
versus the micrometer position. Once the axes were calibrated, the effects of misalignment were measured. The
software alignment overlies the projector and camera image
very accurately in the focal plane, but if there is a misalignment of the optical axes, there will be an increasing misalignment with an increasing distance away from the focal
plane, as illustrated in Fig. 7. A difference between the
distances from the projector lens to the focal plane and
from the camera lens to the focal plane would also result in
some misalignment.
Each optical axis rotation stage was individually adjusted in a range about its aligned position with the other
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Fig. 8 The accuracy of the alignment that uses a four-point phantom image was evaluated using a
one-point phantom image. The four-point phantom image has four 50-pixel-diameter points located at
the corners of a 320 240-pixel rectangle, centered in the image. After the alignment routine had
calculated translation, scaling, and rotation parameters, these parameters were applied to an image
containing one point, so that ideally the coordinates of the point in the projected image would be
identical to the measured coordinates in the captured image. The point was projected onto a fluorescent screen, starting with coordinates of x = 45, y = 30. After the coordinates in the captured image were
measured, the point was reprojected with different coordinates. The coordinates of the projected point
were varied systematically in 15-pixel increments in both x and y, to cover essentially the entire image.
The difference between projected and measured x coordinates is shown in the left graph; the difference between projected and measured y coordinates is shown in the right graph. As expected, the
alignment error is lowest near the pixel coordinates of the points in the alignment phantom, where the
difference is close to zero, but even at the extreme edges of the field of view the error is less than 0.8
pixels for both the x and the y coordinates.
similar to that of the CCD y-axis misalignment. The average slope of the three measured lines is 0.1177. If the mirror were located exactly at the camera lens, then the
508-mm lens-to-arm distance and the 25.4-mm depth of
focus of the lens would imply that the slope should be 0.1.
The slope is slightly more because the mirror is obviously
mounted in front of the lens see Fig. 3.
Figure 11 shows the effects of the projector-lens-tofocal-plane distance being changed while the camera-lensto-focal-plane distance remains fixed. The Y displacement
was less than 0.3 pixels for the entire range of adjustments,
while the X displacement increased from 0.6 to 1.4 pixels.
Keeping the projector micrometer position less than 500
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Optical Engineering
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Shochat, MD, in evaluating the potential of infrared imaging technology for vein contrast enhancement in infants.
We would also like to acknowledge the support and encouragement of Frank A. DiBianca and Mohammad Kiani of
the Department of Biomedical Engineering.
References
1. Pyng Technologies Corp., http://www.pyng.com/pym/products/
problem.htm, Aug. 24, 2001.
2. K. A. Lillis and D. M. Jaffe, Prehospital intravenous access in children, Ann. Emerg. Med. 2112, 14301434 1992.
3. D. D. Brunette and R. Fischer, Intravascular access in pediatric cardiac arrest, Am. J. Emerg. Med. 66, 577579 1988.
4. P. J. Howanitz and R. B. Schifman, Inpatient phlebotomy practices.
A College of American Pathologists Q-Probes quality improvement
study of 2,351,643 phlebotomy requests, Arch. Pathol. Lab Med.
1186, 601605 1994.
5. J. C. Dale and D. A. Novis, Outpatient phlebotomy success and
reasons for specimen rejection, Arch. Pathol. Lab Med. 1264, 416
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6. L. Chameides and M. Hazinski, Textbook of Pediatric Advanced Life
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7. HealthAnswers Inc., http://health.discovery.com/diseasesandcond/
encyclopedia/2938.html Jul. 19, 2002.
8. M. Stovroff and W. G. Teague, Intravenous access in infants and
children, in Pediatric Surgery for the Primary Care Pediatrician,
Part II, M. G. Caty, M. S. Irish, and P. L. Glick, Eds., pp. 13731393,
W.B. Saunders, Philadelphia 1998.
9. Auckland District Health Board, http://www.adhb.co.nz/akhdem/
Guidelines/intraosseus access.htm Feb. 13, 2003.
10. B. W. Davies, Venous cutdown and intraosseous infusion, Update
in Anaesthesia, Issue 5 1995, Article 3; http://www.nda.ox.ac.uk/
wfsa/html/u05/u05 005.htm Feb. 13, 2003.
11. J. P. Orlowski, Emergency alternatives to intravenous access, in
Pediatric Critical Care, J. P. Orlowski, Ed., pp. 11831199, W.B.
Saunders, Philadelphia 1994.
12. M. W. L. Gauderer, Vascular access techniques and devices in the
pediatric patient, in Pediatric Surgery, H. C. Filston, Ed., pp. 1267
1284, W.B. Saunders, Philadelphia 1992.
13. G. Lovhoiden, H. Deshmukh, and H. D. Zeman, Clinical evaluation
of vein contrast enhancement, in Biomedical Optics, Proc. SPIE
4615, 6170 2002.
14. G. Lovhoiden, H. Deshmukh, C. Vrancken, Y. Zhang, H. D. Zeman,
and D. Weinberg, Commercialization of vein contrast enhancement, in Biomedical Optics, Proc. SPIE 4958, 189200 2003.
15. H. D. Zeman, Contrast enhancing illuminator, U.S. Patent No.
5,969,754 1999.
16. H. D. Zeman, Diffuse infrared light imaging system, U.S. Patent
No. 6,556,858 2003.
17. H. D. Zeman and G. Lovhoiden, Enhancing the contrast of subcutaneous veins, Proc. SPIE, 3595, 219230 1999.
18. H. D. Zeman, G. Lovhoiden, and H. Deshmukh, Optimization of
subcutaneous vein contrast enhancement, Proc. SPIE, 3911, 5057
2000.
19. H. D. Zeman, G. Lovhoiden, and H. Deshmukh, Design of a clinical
vein contrast enhancing projector, Proc. SPIE 4254, 204215
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20. C. Vrancken, Image processing software for vein contrast enhancement, Master Project Report, Univ. of Tennessee, Health Science
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Science Center 2002.
Herbert D. Zeman is the chief research officer CRO at Luminetx Corp. Dr. Zeman
invented the Vein Viewer technology and
founded Conenhill Biomedics, which is now
called Luminetx. As CRO, he leads research efforts of the company. Dr. Zeman
received masters and doctoral degrees in
physics from Stanford University. He also
was awarded a post doctoral fellowship at
the Physikalisches Institut der Universitt
Mnster, Mnster, Germany. Dr. Zeman has
held positions at the Molecular Physics Center, SRI International,
Menlo Park, CA; the High Energy Physics Laboratory, Stanford University, Stanford, CA; Xerox Medical Systems, Advanced Imaging
Optical Engineering
Area, Palo Alto, CA; Brookhaven National Laboratory, National Synchrotron Light Source, Upton, NY; and the University of Tennessee
Health Science Center, Department of Biomedical Engineering,
Memphis, TN. Dr. Zeman has published over 80 papers in the fields
of medical imaging and atomic, molecular, and high-energy physics.
He holds three patents in medical imaging, two of which have been
transferred to Luminetx Corp. A fourth patent application has just
been submitted by the University of Tennessee, and Luminetx holds
an option for an exclusive license.
Gunnar Lovhoiden is the director of engineering, Luminetx Corp. Dr. Lovhoiden
worked with Dr. Zeman on the development
of the vein-viewer technology from its inception. As director of engineering, he works
with Dr. Zeman on the research and development of the vein-viewer technology. Dr.
Lovhoiden received his masters and doctoral degrees in biomedical engineering,
with Dr. Zeman as his research advisor, at
the University of Tennessee Health Science
Center in Memphis, TN. After his masters degree, Dr. Lovhoiden
spent one year at Brookhaven National Laboratory collaborating
with Dr. Kelvin Lynn at BNL and Dr. Zeman at UT. He then spent
three years teaching engineering technology at Andrews University
in Berrien Springs, Michigan. After his doctoral degree, Dr.
Lovhoiden spent another year teaching at Andrews University before returning to Memphis to join Luminetx Corp. Dr. Lovhoiden
played a key role in developing the proof-of-principle vein-viewer
device. He has published 16 papers in medical imaging ranging in
subject matter from vein imaging to bone densitometry to dualenergy x-ray imaging of contrast agents.
Carlos Vrancken is the director of software
development at Luminetx Corp. Mr.
Vrancken received his undergraduate degree in biomedical engineering from Universidad Nacional de Entre Rios in Argentina,
and his Master of Science in biomedical engineering from the University of Tennessee
Health Science Center in Memphis, TN.
While at the University of Tennessee he
worked on the project that created the realtime image-processing software for the
vein-viewer device. He has since joined Luminetx as the Director of
Software Development and works with Dr. Zeman on the design,
development, and implementation of all the software applications,
including the image processing algorithms and the human interface
used in the vein viewer. Mr. Vrancken has published four papers on
the vein-viewer technology in addition to his masters thesis.
Robert K. Danish is an Associate Professor of Pediatrics at the University of Tennessee Health Science Center, Memphis, TN.
He received his MD degree from Hahnemann Medical College, Philadelphia, PA. He
did his pediatric residency training at St.
Christophers Hospital for Children in Philadelphia, and a USPHS-NIH research fellowship in pediatric endocrinology at Johns
Hopkins University School of Medicine, Baltimore, MD. He was on the faculty of Case
Western Reserve University School of Medicine and MetroHealth
Medical Center, Cleveland, OH for 22 years before moving to Memphis. He serves as a Pediatric Endocrinologist at Le Bonheur Childrens Medical Center and St. Jude Childrens Research Hospital.
His areas of interest are endocrine system and bone changes in
childhood cancer, acute changes in water and solute balance in
children with severe diabetic ketoacidosis, and development of biomedical engineering devices for the clinical setting and evaluation of
their usefulness in human subjects.
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