Simulation Sessions: Augmented Reality to Improve Pediatric Septic Shock Care

March 4, 2022

Augmented reality (AR) is a revolutionary advancement in medicine that provides health care professionals an interactive experience with superimposed digital media in the real environment. As we better understand the ways AR can enhance the care we provide our patients or the training we offer our health care professionals, simulation can lead the way. In this episode, Dr. Regina Toto, a pediatric emergency medicine physician at the Children’s Hospital of Philadelphia, shares her work developing and testing PediSepsisAR, a first of its kind augmented reality app that can measure the volume and timing of fluid administration during the resuscitation of a pediatric patient in septic shock.


Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, where the complex is our everyday. Each week, we bring you intriguing stories and relevant pediatric healthcare information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for the most amazing people on earth: kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. The future is here. Augmented reality is a revolutionary advancement that helps provide us as clinicians an interactive experience with superimposed digital media on top of our real environment. In this episode, Dr. Regina Toto from the Children’s Hospital of Philadelphia, shares her groundbreaking work developing a first-of-its-kind augmented reality that can help us better care for kids in pediatric septic shock.

Dr. Samreen Vora: Welcome to Sim Sessions with Samreen. Today we are meeting with Dr. Regina Toto to talk about using augmented reality for taking care of pediatric patients with sepsis. Dr. Regina Toto is a pediatric emergency physician attending at the Children’s Hospital of Philadelphia. She is also currently a student in the Master’s of Medical Education Program at the University of Pennsylvania, and will be graduating in the spring. Dr. Toto’s research interests lie within medical education, including simulation, adult learning theory and qualitative methods. Welcome, Regina.

Dr. Regina Toto: Thank you. Happy to be here.

Dr. Samreen Vora: Well, we are so excited to talk to you about some of your work you’ve done recently using augmented reality to improve the care we provide to our pediatric septic patients. I’m wondering if you could share, or maybe you could just start by defining what augmented reality is.

Dr. Regina Toto: So augmented refers to superimposed digital media on the real world environment. In other words, participants who are using augmented reality can see digital media that does not actually exist as being portrayed through another means, but they can also see the things that are around them in the real world.

Dr. Samreen Vora: I was really excited to find this a while back on Google, you can pull up various animals. So for my kids, I was able to superimpose a tiger in our living room and then take pictures of them standing next to the tiger. So is that a good example of what augmented reality is?

Dr. Regina Toto: Yes, that’s a perfect example. The example that I usually give, and maybe you experienced this with your kids a couple years back, was Pokemon GO. Similar idea to what you just mentioned, but you would see a Pokemon, and you could take pictures of yourself with the Pokemon next to you.

Dr. Samreen Vora: At Children’s Minnesota, thinking about taking better care of our pediatric patients with sepsis, we recently launched an alert tool in our electronic medical record system. There’s an incredible team behind the scenes that’s been working on that for some time and in the last weeks have launched the tool and are testing it. In that process, they had come to us, and we had helped to do a small simulation to actually simulate the process they had already identified on paper because there were so many different players. That’s how we had started to use simulation within the process that we’re creating for sepsis and will continue to. In that process, as I was looking for what others have done, I ran into your work and your work was really cool to see this next level of just using technology and collaborating across industries. How did you use that within health care and with simulation?

Dr. Regina Toto: We also have a sepsis alert system at CHOP, and we’re constantly looking to use simulation to help treat septic patients, to educate people on what are the initial steps that you need to take when you’re treating a child with sepsis. Part of the reason why we turned to augmented reality was that when you’re working with a simulation mannequin, you can display vital signs on a monitor, you can have a simulation facilitator say that they have delayed capillary refill or that they have modeling, but your ability to sort of see the signs of sepsis that you would see in a real patient and specifically the signs of impaired perfusion that you would see in a real patient, is limited. That being said, I know there are some more sophisticated models coming out, even now, that can portray those things, but we don’t have them readily available.

So we thought, “How can we better portray impaired perfusion that’s part of sepsis, but how can we do that in a way that people can still practice the important skills in managing a septic patient?” The skill that we chose to focus on was push-pulling fluids. We wanted people to be able to practice that skill, but also to be able to see what’s going on with their patient’s perfusion and to get real time feedback on their patient’s perfusion as they’re performing the intervention of administering IV fluids. I’m lucky to work at Children’s Hospital of Philadelphia, which is affiliated with University of Pennsylvania. At UPenn there was a group led by Marion Leary, who’s a nursing leader and educator, and she had developed an augmented reality model of perfusion called CPR Reality. This model allows people to actually see what happens perfusion-wise when they’re performing CPR.

So we thought, “Okay, we have an existing prototype that our colleagues have worked on,” and Marion was as part of my project too. “How can we adapt that to reflect a simplified model of impaired perfusion in sepsis that changes in a positive way as you give IV fluids?” So, one of the things you mentioned, being interdisciplinary collaboration, which was a huge part of the work that I did, we worked with a local software company to adapt this prototype such that there would be interaction between pushing the syringe and changing of the augmented reality portrayal of perfusion.

So we were able to create that interactivity, and that allowed people to see, “As I’m pushing fluids, the perfusion is getting wider and wider. My patient is better perfused.” So I’m getting that real time feedback as I’m performing the task of giving fluids that I otherwise wouldn’t get in simulation. Sure, you would see the vital signs changing in a positive way. You might hear from a simulation facilitator, “The capillary fill is getting better. It’s now less than two seconds,” but you can’t see it, and we really wanted people to be able to see.

Dr. Samreen Vora: So it’s really cool that you picked that piece and you talk about the push-pull method. I wonder if very briefly you could just explain what that is because I feel like that ties to then what you’re seeing in your patient when you’re able to do that, that quickly.

Dr. Regina Toto: So far as I know, the technique of push-pulling is pretty specific to pediatrics. What that refers to, as opposed to putting fluids on a pump or running them to gravity into a patient, you actually manually pull fluids from a fluid bag into a syringe and then push the fluid into the patient. It’s a way of rapidly getting fluids into a patient that’s active rather than passive, and you’re not relying on a machine to do it. You’re actually manually doing it yourself. So you’re measuring how much you’re giving, and as you mentioned, it’s weight based. So we aim to do this in 20 cc/kg aliquots of fluid with ideally reassessments in between: listening to lungs, feeling for a liver edge to make sure the patient’s not becoming volume overloaded.

Dr. Samreen Vora: The other piece that you mentioned in there, you mentioned that you worked really collaboratively with this tech company. Can you talk a little bit more about that partnership and that experience.

Dr. Regina Toto: It was one of the coolest parts of the project for me. I had never done something like that before, where I was collaborating with a non-medical group of people that have a totally different skillset and knowledge base than I have and together, able to create something that is potentially really helpful in the clinical realm, is definitely helpful from an educational perspective. It was a big learning curve for me, I would say, because I realized quickly that we speak our own sort of medical language. I went to my first meeting with them and I realized, I thought, “Oh my goodness, I really need to now translate what I’m trying to portray to a layperson who doesn’t know much about sepsis, but who knows a whole lot more than I know about augmented reality and the technology involved therein and how to create augmented reality models.”

We had to really communicate well about what the goal was. What we wanted to be able to see, what we wanted the model to be able to do and why that was important. It was just incredible. I’m lucky in that Marion’s group with CPR Reality had already worked with this software company, and the company is very invested in doing things that relate to health care and potentially improving patient care. So they really had a vested interest even before I got in touch with them in working with us. They were just so helpful. I mean, it helped too that they were local. A lot of this actually took place amidst COVID. Even during the pandemic, we were able to meet safely. We were able to collaborate a lot virtually as well. It was just a really incredible experience that I’m not sure I would’ve ever had were it not for this project.

A lot of it, Samreen, really boils down to mutual respect. We had to respect each other’s skill sets, cultures, because we were just working in totally different silos, but we came together and we were able to collaborate in this way to make something truly great.

Dr. Samreen Vora: The incredible work that you can do when you bring those expertise together, effectively communicate to build something. I think for us in simulation, it’s really important. Our work crosses a lot into technology and being able to understand, gosh, technology is really moving forward fast, but how do we harness that to make care for our patients better? How do we harness that within simulation to do that? I think that’s what was really cool about that partnership that you’ve just described.

Dr. Regina Toto: One of the cool parts about working with them too was that they were able to help us create a fluid measurement system that we as medical professionals really didn’t know how to create. So we needed a way to measure how much fluid our participants were giving to their simulated patient during the simulation, because the whole aim of our study, this initial study, was really to look at the feasibility of collecting data on fluid administration and the timing of that while people were using augmented reality and also not in our control group. We really didn’t have a reliable system of measuring that fluid, and they helped us develop a device called a potentiometer, which actually fits inside a 60 cc syringe and then measures the movement of the plunger as the participant is pushing it down. That piece ended up being one of the most novel parts of our project actually, and that device could be used for so many different applications moving forward.

Dr. Samreen Vora: Can you talk a little bit more about that device and the potential of using that continued in simulation as well, but in the real patient environment potentially.

Dr. Regina Toto: We basically went to the software company and said, “We need a way to measure this. What do you think? Here’s the equipment that we’re planning to have people work with? How can we make this work,” and really put our trust in them. They are innovators by nature. They’re such creative folks and really problem oriented, problem solving oriented folks as well. So they took it on as a challenge, and they said, “Let us think about this. Let us tinker with this. Let us work with it.”

So they developed the potentiometer so that it would fit inside the syringe, which was key because really the movement of the syringe plunger was the closest sort of surrogate we could get to, to measure how much fluid was actually going in. The way that it does that is that it actually takes the distance that it travels, and they were able to get it to calculate then how much fluid that would equate to. We had a computer program open while people were participating in the simulation. So we could see on our end, like a facilitator end in real time, how much fluid was going in. I mean, it worked really well for data collection for our project. It’s not perfect obviously because if somebody just didn’t even have fluid in the syringe and just pushed it down or moved it, the potentiometer would record that as if it was fluid administered. So there are limitations with any measurement device. That was a major one for the potentiometer, which we talked about when we published this work.

But I do think it has potential for being a tool we could use at the bedside. Currently when we push-pull fluids, at least to my knowledge, there’s not a standard way to measure that other than humans measuring it as they’re push-pulling, which it would be really great to have a way to have a device measure that or a machine measure that rather than a human who’s stressed, who’s in resuscitation, who’s potentially doing other things while they’re pushing, thinking about other things certainly. So knowing exactly how much fluid the patient’s gotten and really taking that element of human error out of it would be great.

Dr. Samreen Vora: There’s some other findings you had. Do you want to share a little bit about that?

Dr. Regina Toto: We asked people in the AR group if they felt like they were more aware of the perfusion, and participants did feel like they were more aware of the patient’s perfusion than they otherwise would’ve been. This cohort of people, it was an interdisciplinary sample, all of which had done simulation before, familiar with simulation, and so that finding that they were more aware of the patient’s perfusion was valuable to us. There were also a significant proportion of people who found it distracting actually, which was interesting for us to know. It’s definitely a balancing measure, so to speak, when working with any sort of technology, I think, because you have to make sure that it doesn’t take away from the learning exercise in any way.

Using technology is great, but you have to make sure it adds rather than takes away, and some people did feel like it was distracting to them. As we, I think, move forward and design other AR and VR models, we have to make sure that we’re cognizant of what limitations these models may have and in what ways they may actually detract from something like simulation, which is known to be, even in its traditional forms, very valuable for learning.

Dr. Samreen Vora: There are other thoughts about next steps from here?

Dr. Regina Toto: The short answer is there’s lots of thoughts. There’s nothing currently in the works, at least at my institution. But the sort of preliminary thoughts that we had after wrapping up the project were, could we use a model like this to portray different types of shock? Could we use this as a tool to teach people what are the differences specifically between say cardiogenic shock in a child that has myocarditis versus septic shock, and what happens when you give those two patients fluids? Well, you’ll see very different things with their perfusion. So could we use augmented reality and a model like this to portray different types of shock and to show people as they give fluids or do an intervention, what those differences are pathophysiologically? That’s one thought that we had.

I think other groups have done a lot of great work in this realm using AR specifically for not just septic shock, but decompensating patients and being really creative about different ways to show that with modeling and different things like that. So the sky is the limit as far as future opportunities.

The other thing that I always have to think about is could we ever bring this to the bedside? What I’m getting at is could you actually use data from a patient in real time to create an augmented reality model of what’s going on inside their body with their perfusion or with other organ functions and things like that? Could that be used as data to help guide their care? That’s where all of this, I think, is eventually headed. I mean, right now we’re using it as a way to enhance education. But I do think as the years pass, we will see more moves towards bringing this to the actual bedside, which would be so cool.

Dr. Samreen Vora: Another example of that being done is 3D printing. You think if you had talked a number of years ago, it would have been like, “oh, that’s crazy,” and now we see we’re using actual patient physiology, anatomy and printing it and practicing procedures or teaching patients about what the procedure is going to be done on them on an actual model of their own heart or other body parts. I think that’s a great example of how this technology might progress as well, like you said, to the bedside.

Dr. Regina Toto: The technology is just so fast moving. The HoloLens that I used as part of my study before we even got to the point of enrolling people was not obsolete, but there were three new versions of it that existed. So just the pace is incredibly fast, and I think that’s what makes this very exciting too.

Dr. Samreen Vora: To start to wrap up our conversation, I’m just so excited to hear about your work, the potential next steps. Is there anything else you want to share?

Dr. Regina Toto: I would just say my message to trainees, because I was a fellow when I was doing this research, is to not be afraid to think out of the box and to go in a different direction than you thought you were going to go. I’m somebody that’s long been interested in medical education and simulation as well. I never in a million years thought that I would be doing a project utilizing augmented reality. I didn’t even know what it was before I began my fellowship. I would say to trainees out there, especially, to be open to new opportunities and definitely be open to collaborating with people who are not in medicine. You will learn a ton, and we can really grow in our efforts by working with those people. So don’t be afraid to try things on like this for size, and you’ll be surprised at what you can accomplish.

Dr. Samreen Vora: I love that advice, and I would expand your advice to even practicing professionals. Don’t be afraid.

Dr. Regina Toto: Totally. Why not?

Dr. Samreen Vora: To look outside your field, outside your discipline. Absolutely. I love it. That was wonderful. Well, thank you so much for joining us today. I look forward to having further conversations with you in the future.

Dr. Regina Toto: This was so much fun.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Lexi Dingman is our marketing representative. For more information and additional episodes, visit us at, and to rate and review our show, please go to