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Low-Cost Bicycle Lights vs. Cold Lights for Visualizing Neonatal Veins

Low-Cost Bicycle Lights vs. Cold Lights for Visualizing Neonatal Veins Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 Journal of Tropical Pediatrics, 2018, 64, 202–207 doi: 10.1093/tropej/fmx049 Advance Access Publication Date: 10 August 2017 Original paper Low-Cost Bicycle Lights vs. Cold Lights for Visualizing Neonatal Veins 1 2 3 by Neal J. Russell, Paul Bassett, and John Chang London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK Statsconsultancy Ltd, Amersham, Bucks HP7 9EN, UK Croydon Research Department, Croydon University Hospital, Croydon, Surrey CR7 7YE, UK Correspondence to: Neal Russell, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel: 07564952387. E-mail <[email protected]>. ABSTRACT Objective: Difficult intravenous (IV) access can compromise patient care in neonatal practice, and transillumination is often used to improve the visibility of veins. Current devices are expensive, prone to bacterial contamination and unaffordable in low-resource settings. We conducted a study comparing the quality of transillumination provided by "cold lights" that are currently in use with low-cost (<£1) red silicone LED bicycle lights. Methods: Photographs of the hands and feet of neonates were taken with parental consent: first without transillumination (control group), second by transillumination with a cold light, and third with a bicycle light. Thirty photographs were sent in a survey to pediatric doctors who were blinded to the method of transillumination. Survey respondents then rated the visibility of the veins (easily visible, moderately visible, barely visible and invisible). Results: Completed surveys of 114 respondents were included in the analysis. The majority (94.8%) of respondents rated the veins moderately to easily visible with the bicycle light compared with 87.6% with the cold light, and 42.6% in the control group with no transillumination. There was a strong evi- dence of an improvement in visibility with bicycle lights compared with cold lights (p< 0.001). Conclusion: Low-cost red silicone LED bicycle lights were found to improve visibility of veins in neonates. Given their quality of transillumination, portability and reduced cost, they may provide a useful method of transillumination in all settings, but particularly in low-income settings, where there is currently no affordable alternative. KEYWORDS: difficult intravenous access, intravenous cannulation, venepuncture, neonatal, transillumination BACKGROUND prone to bacterial contamination, can be difficult to use Difficult intravenous (IV) access is a long-standing and in a clean or sterile manner, and are expensive. Their familiar problem in neonatology and pediatrics, and risk of cross-infection was highlighted recently in an can significantly compromise clinical care in some cir- unpublished study showing the cold light to be the cumstances. Transillumination has been recognized as most heavily contaminated piece of equipment on our a useful technique in overcoming this challenge for neonatal unit, for example (L. Young, Unpublished) some time [1–5]. However, the devices most com- [6]. Given their cost, cold lights are often shared monly used for transillumination (cold lights) are among many babies, and could therefore be a vector of V The Author [2017]. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.  202 Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 Low-Cost Bicycle Lights vs. Cold Lights  203 METHODS hospital-acquired infections (similar to stethoscopes). New methods such as infra-red devices are being de- An online survey comparing the visibility of bicycle lights and cold lights was conducted. Neonates in veloped to overcome these issues, but are even more expensive and their effectiveness has not been consist- the Neonatal Unit at Croydon University Hospital were selected opportunistically between December ently demonstrated [7, 8, 12–14]. Ultrasound is emerg- ing as a useful method for obtaining longer term IV 2014 and January 2015. Babies who were clinically unstable or whose parents did not provide consent access in deeper veins, but is also expensive and less useful for standard peripheral IV access in superficial were excluded. veins in neonates [9]. Therefore, there is a need for Sets of three photographs were taken of hands low-cost, user-friendly and safe devices with minimal and feet (i) with no transillumination (control), infection risk—particularly in low-income countries (ii) with transillumination with a cold light, and where the majority of neonatal deaths occur [10], and (iii) with a red silicone LED bicycle light (Figs 1 and where all currently available transillumination devices 2). Photos were taken in the Neonatal Intensive are unaffordable. Care and Special Care Baby Unit in the normal clin- Red silicone LED bicycle lights, which have anec- ical environment. Babies remained in their incuba- dotally been used for IV cannulation and venepunc- tors, the background lighting being dimmed to the ture, as well as arterial access and peripherally inserted central lines, are a possible low-cost alternative method for transillumination. At a cost of less than £1 each, compared to £100s–1000s for most of the other de- vices on the market, their economic advantage is clear. They are also easily portable, and owing to their small size can be completely enclosed inside clinical or ster- ile gloves (unlike most cold lights), reducing the risk of transmission of infection. In terms of safety, the red silicone LED bicycle lights used in this study use similar LED technology to many Fig. 1. An example of a red silicone LED bicycle light of the cold lights currently in use. Formal testing locally (available from many different manufacturers). demonstrated no rise in temperature with use, and a power output of 226 mW/cm ,muchlessthanother devices used on neonates such as cranial ultrasounds whose output is 800 mW/cm . In terms of radiation emission, although there is no accepted limit, there should be no safety concerns with bicycle lights used for short periods given that use of lasers with similar power outputs for up to 8 h is considered safe [11]. A similar time period to that recommended for cold lights (up to 4 min) would be reasonable. Furthermore, purely red lights are thought to be safer than white lights which are often used in cold lights [11]. To our knowledge, there are no published studies looking at low-cost methods of transillumination, as most research has been driven by new development of expensive medical devices. We set out to test the quality of transillumination provided by low-cost red silicone LED bicycle lights in neonates by comparing Fig. 2. Example of transillumination with an LED bicycle light. them with a standard cold light currently in use. Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 204  Low-Cost Bicycle Lights vs. Cold Lights same level for the cold lights and bicycle lights, and This survey was conducted within the context of kept at normal room lighting for photos without a randomized controlled trial comparing the use of transillumination. The bicycle lights were enclosed cold lights and bicycle lights for intravenous cannula- in a clinical glove, which is how we propose they tion, which received ethical approval from the NHS should be used in practice to reduce infection risk. Research Ethics Committee (Ref: 14/LO/1723). Photographs were taken by a team of two re- Screening on the same IRAS system provided writ- searchers with an iPhone 4s. One researcher held the ten confirmation that separate ethical approval was hand or foot of the baby, without a tourniquet, and not required. Written consent was obtained from the other took the photographs. Strict infection parents after being given an information leaflet, and control procedures were adhered to throughout. The given the opportunity to ask questions. It was best quality photograph was selected among several ensured that no photographs contained identifiable of the same limb and transillumination approach. information on any of the babies. Sixty photos of 20 hands or feet (with a control, cold light and red LED light picture of each) were used in RESULTS a pilot survey with 12 independent respondents. Ten sets of three photographs (control, cold light Based on respondents’ feedback, the number of and bicycle light) of hands or feet from five neonates photos was cut down to 30 (10 hands or feet from were included in the final survey. The characteristics five babies) after removing pictures of lower quality. of these five babies are presented in Table 1. The on- We designed an online survey including 10 sets of line survey was sent by email to 281 pediatric doc- three photographs (one control, one cold light and tors in training in the south London deanery, of one bike light) from each hand or foot. The best qual- whom 128 responded. Fourteen questionnaires were ity photographs from each limb were chosen to limit excluded owing to missing responses for 40% variation in quality. All photographs were reshuffled questions. randomly for each respondent, who were asked to As shown in Table 2 and Chart 1, among the 114 rate the ease of visibility of veins for intravenous can- responses analysed, respondents considered the nulation (invisible, barely visible, moderately visible or veins of babies to be moderately or easily visible in easily visible). Respondents were blinded both to the 94.8% of cases when illuminated with bicycle light, method of transillumination in the photographs, as compared with 87.6% with cold light, and 42.6% of well as to the purpose of the study. cases in the control group without transillumination. For statistical analysis, the data were considered to The multilevel logistic regression model (shown in be clustered and non-independent at the levels of the Table 3) demonstrated that, compared with no light, observers and individual body parts, as a given obser- the odds of veins being moderately to easily visible ver may rate photographs in a certain way, and there were higher for both cold light [OR 12.5 (9.92–15.8)] are likely to be similarities in the way observers rate and bicycle light [OR 34.1 (25.1–46.3)]. The bicycle particular body parts. A multilevel logistic regression model with random effects was carried out, with a Table 1. Characteristics of babies included in cross-classified structure for both body part and ob- final survey server. Ease of visibility (the outcome variable) was categorized into a binary variable with categories Gestational Corrected Current Ethnicity Invisible/Barely visible and Moderately/Easily visible. Age at Gestational Weight Birth Age (g) The multilevel regression model also included skin colour (black or white) as an explanatory variable. Baby 1 28þ232þ5 1374 Afro-Caribbean We tested the hypothesis that the effect of bicycle Baby 2 28þ232þ5 1330 Afro-Caribbean light on visibility would differ by skin colour by exam- Baby 3 28þ537þ3 2510 Afro-Caribbean ining the p-value for an interaction term between Baby 4 36þ336þ6 1774 Caucasian skin colour and type of light. Statistical analyses were Baby 5 30þ034þ1 2096 Caucasian carried out using Stata Version 13.1. Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 Low-Cost Bicycle Lights vs. Cold Lights  205 Table 2. Responses by light source in study Invisible Barely Visible Moderately Visible Easily Visible Total Responses No light 162 (14.2%) 492 (43.3%) 369 (32.7%) 113 (9.9%) 1136 Cold light 15 (1.3%) 126 (11.1%) 312 (27.6%) 679 (60%) 1132 Bike light 5 (0.4%) 54 (4.8%) 347 (30.6%) 728 (64.2%) 1134 lights is at least equivalent to that of standard cold lights, and may be better. Two-thirds (64%) of doc- tors in our sample judged neonates’ veins to be easily visible with bicycle lights, and a further 31% moder- ately visible (compared with 60% and 28% for cold lights, respectively). These results suggest that LED bicycle lights are a good alternative to standard cold lights. There are several potential justifications for using these bicycle lights for IV cannulation of neonates. First, their low cost (<£1) provides a strong economic Chart 1. Visibility of veins by method of transillumination. argument even without their observed improved trans- illumination over standard cold lights, and may allow Table 3. Odds of moderate/easy visibility by for increased availability of transillumination devices on light source: multilevel regression the wards (perhaps even for single use). Second, even without considering single-use, the ability to completely Variable Comparison Odds Ratio p-value enclose the bicycle lights inside gloves reduces the risk Light type Cold light 12.5 (9.92, 15.8) <0.001 of cross-infection compared with cold lights, many of vs. None which cannot be enclosed in such a way. The reality is Bike light 34.1 (25.1, 46.3) <0.001 that in a neonatal unit, owing to their cost, one or two vs. None cold lights are shared amongst several babies, raising Bike light vs. 2.72 (1.97, 3.76) <0.001 concerns given their susceptibility to bacterial contam- Cold light ination. This situation is reminiscent of the concerns Skin colour Black/White 1.17 (0.42, 3.22) 0.76 with stethoscopes, which were likely acting as vectors of hospital-acquired infections before the policy of Note: Using a cross-classified structure, with random effects for both par- ticipant and body part. ‘one stethoscope per baby’ was adopted. Therefore, the use of red LED bicycle lights (whether single-use or enclosed within gloves) has the potential to prompt light also performed better than the cold light a shift in practice which could reduce this cross- [OR 2.72 (1.97–3.76)]. infection risk. Aside from these advantages in settings There was no evidence of an interaction between where cold lights are already available, red LED bicycle type of light and skin colour (p-value for the inter- lights represent a possible low-cost option for transillu- action term¼ 0.13), and neither did skin colour af- mination in low-resource setting where there are no fect the visibility of veins in our sample (OR 1.17, other affordable options. In theory, any red LED light 0.42–3.22). There were no adverse events in any of which is affordable and of appropriate size could be the subjects in the study. used for this purpose. The results of the study are strengthened by the DISCUSSION large number of respondents (114) each rating the This study demonstrates that the quality of transillu- visibility of veins in 30 photographs with few missing mination with low-cost red silicone LED bicycle data (0.5% missing answers in analysed responses), Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 206  Low-Cost Bicycle Lights vs. Cold Lights WHAT IS ALREADY KNOWN ON THIS all of whom were pediatric doctors who regularly cannulate neonates. Bias was minimized by selecting TOPIC? babies without prior examination of their veins, and Transillumination is a useful technique for by blinding participants to the method of transillu- difficult intravenous cannulation, particularly mination and to the purpose of the study. The se- in neonates quence of individual photographs was randomized Current devices are expensive, unaffordable (across babies and methods), to minimize any poten- in low-resource settings tial bias related to order of appearance. WHAT THIS STUDY ADDS Limitations of the study included variations in Red silicone LED bicycle lights, costing picture quality; however, this was minimized by tak- <£1, are at least as good as cold lights for ing large numbers of photographs (187) on the same improving the visibility of veins in neonates camera, from which the 30 best quality photos were These bicycle lights could be used in low- selected, and included photographs were from the resource settings where alternative methods same camera, affecting each group equally. Bias in are unaffordable photograph selection was minimized by selecting Where cold lights are available, red LED these photographs based on image quality rather bicycle lights may be an alternative method than transillumination quality and on assessments of of transillumination with several clinical 60 photographs from independent doctors not advantages such as lower risk of cross- involved in the study. Owing to the potential for re- infection spondent attrition in long surveys, it was decided to restrict the number of photographs to 30 to increase ACKNOWLEDGEMENTS completeness of responses. This was of particular im- We would like to acknowledge the staff in the Neonatal Unit, portance given the random order of the question- the Croydon University Hospital Research team, as well as naires, and need for all three photograph categories the babies and their parents who consented to this study. We from each body part to be rated by each respondent would also like to thank South West London Academic to allow comparison of techniques. Health and Social Care System for funding this work. This study included limited variation in age (32– 37 weeks corrected), with no data on other ages, but FUNDING it could be expected as with cold lights that bicycle The study was funded by South West London Academic Health and Social Care System. Dr Neal Russell is supported lights could be used in older children depending on by NIHR funding for an Academic Clinical Fellowship in hand or foot width. Pediatrics. CONCLUSION REFERENCES Red silicone LED bicycle lights, costing <£1, are at 1. Yamakazi S, Tomita S, Watanabe M, et al. Effects of a least as effective as standard cold light sources in pro- transmitted light device for paediatric peripheral vene- ducing high quality transillumination of veins in neo- puncture and intravenous cannulation. Med Devices nates. Given the obvious economic advantages, the 2011;4:189–92. likely reduced risk of cross-infection with their use 2. Balasubramanian VP, Yasin S, Urquhart DS, et al. Cold inside gloves, and their portability, they should be con- light transillumination as an aid to umbilical catheterisa- sidered for use in neonates. Randomized controlled tion. Arch Dis Child 2003;88:5. 3. Pearce RG. Percutaneous cannulation of the radial artery trial evidence comparing success rate of cannulation in newborn babies using transillumination. Arch Dis Child between cold lights and red LED bicycle lights would 1978;53:549–54. be useful in assessing further the effectiveness of these 4. Mbamalu D, Banerjee A. Methods of obtaining peripheral lights. However, in settings where no other transillu- venous access in difficult situations. Postgrad Med J mination devices are available, clinicians should already 1999;76:459–62. consider using a red LED bicycle light when faced 5. Sieh A, Brentin L. A little light makes venepuncture easier. with a baby with difficult veins. RN 1993;56:40–3. Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 Low-Cost Bicycle Lights vs. Cold Lights  207 6. Young L. ATP Bacterial Contamination Monitoring on publications/files/SOWC_2015_Summary_and_Tables. SCBU, November 2013 and Jaunary 2014. Unpublished. pdf (19 February 2016, date last accessed). Croydon University Hospital. 11. Pfefer TJ, Mehrabi A, James R, et al. Optical-thermal char- 7. Perry AM, Caviness AC, Hsu DC. Efficacy of near infra- acterisation of cutaneous transilluminators. Phys Med Biol red light device in paediatric intravenous cannulation: a 2009;54:6867–80. randomised controlled trial. Paediatr Emerg Care 12. Kim MJ, Park JM, Rhee N, et al. Efficacy of VeinViewer in 2011;27:5–10. pediatric peripheral intravenous access: a randomised con- 8. de Graaff JC, Cuper NJ, van Dijk AT, et al. Evaluating NIR trolled trial. Eur J Paediatr 2012;171:1121–5. vascular imaging to support intravenous cannulation in 13. Szmuk P, Steiner J, Pop RB, et al. The VeinViewer vascular awake children difficult to cannulate; a randomized clinical imaging system worsens first-attempt cannulation rate trial. Paediatr Anaesth 2014;24:1174–9. for experienced nurses in infants and children with 9. Heinrichs J, Fritze Z, Vandermeer B, et al. Ultrasono anticipated difficult intravenous access. Anaesth Analg graphically guided peripheral intravenous cannulation of 2013;116:1087–92. children and adults: a systematic review and meta-analysis. 14. Heinrichs J, Fritze Z, Klassen T, et al. A systematic review Ann Emerg Med 2013;61:444–54. and meta-analysis of new interventions for peripheral intra- 10. UNICEF State of the World’s Children 2015. United venous cannulation in children. Pediatr Emerg Care Nations Children’s Fund 2014. http://www.unicef.org/ 2013;29:858–66. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Tropical Pediatrics Oxford University Press

Low-Cost Bicycle Lights vs. Cold Lights for Visualizing Neonatal Veins

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Oxford University Press
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Copyright © 2022 Oxford University Press
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0142-6338
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1465-3664
DOI
10.1093/tropej/fmx049
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Abstract

Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 Journal of Tropical Pediatrics, 2018, 64, 202–207 doi: 10.1093/tropej/fmx049 Advance Access Publication Date: 10 August 2017 Original paper Low-Cost Bicycle Lights vs. Cold Lights for Visualizing Neonatal Veins 1 2 3 by Neal J. Russell, Paul Bassett, and John Chang London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK Statsconsultancy Ltd, Amersham, Bucks HP7 9EN, UK Croydon Research Department, Croydon University Hospital, Croydon, Surrey CR7 7YE, UK Correspondence to: Neal Russell, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Tel: 07564952387. E-mail <[email protected]>. ABSTRACT Objective: Difficult intravenous (IV) access can compromise patient care in neonatal practice, and transillumination is often used to improve the visibility of veins. Current devices are expensive, prone to bacterial contamination and unaffordable in low-resource settings. We conducted a study comparing the quality of transillumination provided by "cold lights" that are currently in use with low-cost (<£1) red silicone LED bicycle lights. Methods: Photographs of the hands and feet of neonates were taken with parental consent: first without transillumination (control group), second by transillumination with a cold light, and third with a bicycle light. Thirty photographs were sent in a survey to pediatric doctors who were blinded to the method of transillumination. Survey respondents then rated the visibility of the veins (easily visible, moderately visible, barely visible and invisible). Results: Completed surveys of 114 respondents were included in the analysis. The majority (94.8%) of respondents rated the veins moderately to easily visible with the bicycle light compared with 87.6% with the cold light, and 42.6% in the control group with no transillumination. There was a strong evi- dence of an improvement in visibility with bicycle lights compared with cold lights (p< 0.001). Conclusion: Low-cost red silicone LED bicycle lights were found to improve visibility of veins in neonates. Given their quality of transillumination, portability and reduced cost, they may provide a useful method of transillumination in all settings, but particularly in low-income settings, where there is currently no affordable alternative. KEYWORDS: difficult intravenous access, intravenous cannulation, venepuncture, neonatal, transillumination BACKGROUND prone to bacterial contamination, can be difficult to use Difficult intravenous (IV) access is a long-standing and in a clean or sterile manner, and are expensive. Their familiar problem in neonatology and pediatrics, and risk of cross-infection was highlighted recently in an can significantly compromise clinical care in some cir- unpublished study showing the cold light to be the cumstances. Transillumination has been recognized as most heavily contaminated piece of equipment on our a useful technique in overcoming this challenge for neonatal unit, for example (L. Young, Unpublished) some time [1–5]. However, the devices most com- [6]. Given their cost, cold lights are often shared monly used for transillumination (cold lights) are among many babies, and could therefore be a vector of V The Author [2017]. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.  202 Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 Low-Cost Bicycle Lights vs. Cold Lights  203 METHODS hospital-acquired infections (similar to stethoscopes). New methods such as infra-red devices are being de- An online survey comparing the visibility of bicycle lights and cold lights was conducted. Neonates in veloped to overcome these issues, but are even more expensive and their effectiveness has not been consist- the Neonatal Unit at Croydon University Hospital were selected opportunistically between December ently demonstrated [7, 8, 12–14]. Ultrasound is emerg- ing as a useful method for obtaining longer term IV 2014 and January 2015. Babies who were clinically unstable or whose parents did not provide consent access in deeper veins, but is also expensive and less useful for standard peripheral IV access in superficial were excluded. veins in neonates [9]. Therefore, there is a need for Sets of three photographs were taken of hands low-cost, user-friendly and safe devices with minimal and feet (i) with no transillumination (control), infection risk—particularly in low-income countries (ii) with transillumination with a cold light, and where the majority of neonatal deaths occur [10], and (iii) with a red silicone LED bicycle light (Figs 1 and where all currently available transillumination devices 2). Photos were taken in the Neonatal Intensive are unaffordable. Care and Special Care Baby Unit in the normal clin- Red silicone LED bicycle lights, which have anec- ical environment. Babies remained in their incuba- dotally been used for IV cannulation and venepunc- tors, the background lighting being dimmed to the ture, as well as arterial access and peripherally inserted central lines, are a possible low-cost alternative method for transillumination. At a cost of less than £1 each, compared to £100s–1000s for most of the other de- vices on the market, their economic advantage is clear. They are also easily portable, and owing to their small size can be completely enclosed inside clinical or ster- ile gloves (unlike most cold lights), reducing the risk of transmission of infection. In terms of safety, the red silicone LED bicycle lights used in this study use similar LED technology to many Fig. 1. An example of a red silicone LED bicycle light of the cold lights currently in use. Formal testing locally (available from many different manufacturers). demonstrated no rise in temperature with use, and a power output of 226 mW/cm ,muchlessthanother devices used on neonates such as cranial ultrasounds whose output is 800 mW/cm . In terms of radiation emission, although there is no accepted limit, there should be no safety concerns with bicycle lights used for short periods given that use of lasers with similar power outputs for up to 8 h is considered safe [11]. A similar time period to that recommended for cold lights (up to 4 min) would be reasonable. Furthermore, purely red lights are thought to be safer than white lights which are often used in cold lights [11]. To our knowledge, there are no published studies looking at low-cost methods of transillumination, as most research has been driven by new development of expensive medical devices. We set out to test the quality of transillumination provided by low-cost red silicone LED bicycle lights in neonates by comparing Fig. 2. Example of transillumination with an LED bicycle light. them with a standard cold light currently in use. Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 204  Low-Cost Bicycle Lights vs. Cold Lights same level for the cold lights and bicycle lights, and This survey was conducted within the context of kept at normal room lighting for photos without a randomized controlled trial comparing the use of transillumination. The bicycle lights were enclosed cold lights and bicycle lights for intravenous cannula- in a clinical glove, which is how we propose they tion, which received ethical approval from the NHS should be used in practice to reduce infection risk. Research Ethics Committee (Ref: 14/LO/1723). Photographs were taken by a team of two re- Screening on the same IRAS system provided writ- searchers with an iPhone 4s. One researcher held the ten confirmation that separate ethical approval was hand or foot of the baby, without a tourniquet, and not required. Written consent was obtained from the other took the photographs. Strict infection parents after being given an information leaflet, and control procedures were adhered to throughout. The given the opportunity to ask questions. It was best quality photograph was selected among several ensured that no photographs contained identifiable of the same limb and transillumination approach. information on any of the babies. Sixty photos of 20 hands or feet (with a control, cold light and red LED light picture of each) were used in RESULTS a pilot survey with 12 independent respondents. Ten sets of three photographs (control, cold light Based on respondents’ feedback, the number of and bicycle light) of hands or feet from five neonates photos was cut down to 30 (10 hands or feet from were included in the final survey. The characteristics five babies) after removing pictures of lower quality. of these five babies are presented in Table 1. The on- We designed an online survey including 10 sets of line survey was sent by email to 281 pediatric doc- three photographs (one control, one cold light and tors in training in the south London deanery, of one bike light) from each hand or foot. The best qual- whom 128 responded. Fourteen questionnaires were ity photographs from each limb were chosen to limit excluded owing to missing responses for 40% variation in quality. All photographs were reshuffled questions. randomly for each respondent, who were asked to As shown in Table 2 and Chart 1, among the 114 rate the ease of visibility of veins for intravenous can- responses analysed, respondents considered the nulation (invisible, barely visible, moderately visible or veins of babies to be moderately or easily visible in easily visible). Respondents were blinded both to the 94.8% of cases when illuminated with bicycle light, method of transillumination in the photographs, as compared with 87.6% with cold light, and 42.6% of well as to the purpose of the study. cases in the control group without transillumination. For statistical analysis, the data were considered to The multilevel logistic regression model (shown in be clustered and non-independent at the levels of the Table 3) demonstrated that, compared with no light, observers and individual body parts, as a given obser- the odds of veins being moderately to easily visible ver may rate photographs in a certain way, and there were higher for both cold light [OR 12.5 (9.92–15.8)] are likely to be similarities in the way observers rate and bicycle light [OR 34.1 (25.1–46.3)]. The bicycle particular body parts. A multilevel logistic regression model with random effects was carried out, with a Table 1. Characteristics of babies included in cross-classified structure for both body part and ob- final survey server. Ease of visibility (the outcome variable) was categorized into a binary variable with categories Gestational Corrected Current Ethnicity Invisible/Barely visible and Moderately/Easily visible. Age at Gestational Weight Birth Age (g) The multilevel regression model also included skin colour (black or white) as an explanatory variable. Baby 1 28þ232þ5 1374 Afro-Caribbean We tested the hypothesis that the effect of bicycle Baby 2 28þ232þ5 1330 Afro-Caribbean light on visibility would differ by skin colour by exam- Baby 3 28þ537þ3 2510 Afro-Caribbean ining the p-value for an interaction term between Baby 4 36þ336þ6 1774 Caucasian skin colour and type of light. Statistical analyses were Baby 5 30þ034þ1 2096 Caucasian carried out using Stata Version 13.1. Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 Low-Cost Bicycle Lights vs. Cold Lights  205 Table 2. Responses by light source in study Invisible Barely Visible Moderately Visible Easily Visible Total Responses No light 162 (14.2%) 492 (43.3%) 369 (32.7%) 113 (9.9%) 1136 Cold light 15 (1.3%) 126 (11.1%) 312 (27.6%) 679 (60%) 1132 Bike light 5 (0.4%) 54 (4.8%) 347 (30.6%) 728 (64.2%) 1134 lights is at least equivalent to that of standard cold lights, and may be better. Two-thirds (64%) of doc- tors in our sample judged neonates’ veins to be easily visible with bicycle lights, and a further 31% moder- ately visible (compared with 60% and 28% for cold lights, respectively). These results suggest that LED bicycle lights are a good alternative to standard cold lights. There are several potential justifications for using these bicycle lights for IV cannulation of neonates. First, their low cost (<£1) provides a strong economic Chart 1. Visibility of veins by method of transillumination. argument even without their observed improved trans- illumination over standard cold lights, and may allow Table 3. Odds of moderate/easy visibility by for increased availability of transillumination devices on light source: multilevel regression the wards (perhaps even for single use). Second, even without considering single-use, the ability to completely Variable Comparison Odds Ratio p-value enclose the bicycle lights inside gloves reduces the risk Light type Cold light 12.5 (9.92, 15.8) <0.001 of cross-infection compared with cold lights, many of vs. None which cannot be enclosed in such a way. The reality is Bike light 34.1 (25.1, 46.3) <0.001 that in a neonatal unit, owing to their cost, one or two vs. None cold lights are shared amongst several babies, raising Bike light vs. 2.72 (1.97, 3.76) <0.001 concerns given their susceptibility to bacterial contam- Cold light ination. This situation is reminiscent of the concerns Skin colour Black/White 1.17 (0.42, 3.22) 0.76 with stethoscopes, which were likely acting as vectors of hospital-acquired infections before the policy of Note: Using a cross-classified structure, with random effects for both par- ticipant and body part. ‘one stethoscope per baby’ was adopted. Therefore, the use of red LED bicycle lights (whether single-use or enclosed within gloves) has the potential to prompt light also performed better than the cold light a shift in practice which could reduce this cross- [OR 2.72 (1.97–3.76)]. infection risk. Aside from these advantages in settings There was no evidence of an interaction between where cold lights are already available, red LED bicycle type of light and skin colour (p-value for the inter- lights represent a possible low-cost option for transillu- action term¼ 0.13), and neither did skin colour af- mination in low-resource setting where there are no fect the visibility of veins in our sample (OR 1.17, other affordable options. In theory, any red LED light 0.42–3.22). There were no adverse events in any of which is affordable and of appropriate size could be the subjects in the study. used for this purpose. The results of the study are strengthened by the DISCUSSION large number of respondents (114) each rating the This study demonstrates that the quality of transillu- visibility of veins in 30 photographs with few missing mination with low-cost red silicone LED bicycle data (0.5% missing answers in analysed responses), Downloaded from https://academic.oup.com/tropej/article/64/3/202/4080245 by DeepDyve user on 20 July 2022 206  Low-Cost Bicycle Lights vs. Cold Lights WHAT IS ALREADY KNOWN ON THIS all of whom were pediatric doctors who regularly cannulate neonates. Bias was minimized by selecting TOPIC? babies without prior examination of their veins, and Transillumination is a useful technique for by blinding participants to the method of transillu- difficult intravenous cannulation, particularly mination and to the purpose of the study. The se- in neonates quence of individual photographs was randomized Current devices are expensive, unaffordable (across babies and methods), to minimize any poten- in low-resource settings tial bias related to order of appearance. WHAT THIS STUDY ADDS Limitations of the study included variations in Red silicone LED bicycle lights, costing picture quality; however, this was minimized by tak- <£1, are at least as good as cold lights for ing large numbers of photographs (187) on the same improving the visibility of veins in neonates camera, from which the 30 best quality photos were These bicycle lights could be used in low- selected, and included photographs were from the resource settings where alternative methods same camera, affecting each group equally. Bias in are unaffordable photograph selection was minimized by selecting Where cold lights are available, red LED these photographs based on image quality rather bicycle lights may be an alternative method than transillumination quality and on assessments of of transillumination with several clinical 60 photographs from independent doctors not advantages such as lower risk of cross- involved in the study. Owing to the potential for re- infection spondent attrition in long surveys, it was decided to restrict the number of photographs to 30 to increase ACKNOWLEDGEMENTS completeness of responses. This was of particular im- We would like to acknowledge the staff in the Neonatal Unit, portance given the random order of the question- the Croydon University Hospital Research team, as well as naires, and need for all three photograph categories the babies and their parents who consented to this study. We from each body part to be rated by each respondent would also like to thank South West London Academic to allow comparison of techniques. Health and Social Care System for funding this work. This study included limited variation in age (32– 37 weeks corrected), with no data on other ages, but FUNDING it could be expected as with cold lights that bicycle The study was funded by South West London Academic Health and Social Care System. Dr Neal Russell is supported lights could be used in older children depending on by NIHR funding for an Academic Clinical Fellowship in hand or foot width. Pediatrics. CONCLUSION REFERENCES Red silicone LED bicycle lights, costing <£1, are at 1. Yamakazi S, Tomita S, Watanabe M, et al. Effects of a least as effective as standard cold light sources in pro- transmitted light device for paediatric peripheral vene- ducing high quality transillumination of veins in neo- puncture and intravenous cannulation. Med Devices nates. 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Journal

Journal of Tropical PediatricsOxford University Press

Published: Jun 1, 2018

Keywords: newborn; transillumination; foot

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