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Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Adrenal Crisis: Avoidance in Pregnant Women at Risk (520)

Please report any inaccuracies or issues with this guideline using our online form

Glucocorticoid dependent obstetric patients are not encountered commonly, however appropriate care is crucial to avoid potentially life threatening acute adrenal crisis. In order to avoid a precipitous fall in BP during anaesthesia or in the immediate postoperative period, anaesthetists must know whether a patient is taking or has been taking glucocorticoids. 

Signs of acute adrenal crisis include severe dehydration, pale clammy skin, sweating, rapid and shallow breathing, hypotension, dizziness, vomiting and diarrhoea and severe drowsiness or loss of consciousness.

Women at risk [1]

  1. All women requiring long term glucocorticoid replacement (for example as a result of pituitary disease or congenital adrenal hyperplasia, or women with Addison’s disease). These women will usually be receiving the equivalent of 20-25mg hydrocortisone per day and are likely to be dependent on this replacement.1
  2. Women receiving exogenous glucocorticoid may now be dependent on this and develop adrenal crisis if they are stopped suddenly. This group of women includes:
    1. Patients taking the equivalent of 5mg prednisolone per day for more than FOUR See Appendix 1 for more detail.2
    2. Patients on more than the equivalent of 40mg prednisolone per day for more than 7 days2
    3. Patients on long term high dose inhaled steroids. See Appendix 2 for more detail.2
    4. High doses of topical steroids (e.g. ≥200g per week of potent or very potent steroids). See Appendix 3 for more detail. 2

Mineralocorticoids

Note that women with adrenal disease (e.g. Addisons disease or previous bilateral adrenalectomy) may also be receiving mineralocorticoid replacement, usually in the form of fludrocortisone. This also needs to be considered and likely continued.

Factors which can precipitate Adrenal Crisis

  • Infection.
  • Major surgery (e.g. caesarean section).
  • Malabsorption of oral steroids (e.g. due to vomiting).
  • Major stress (e.g. labour).
  • Discontinuation of glucocorticoids (hydrocortisone, prednisolone, dexamethasone).

Peripartum Steroid Management [4]

Caesarean Section

On day of surgery

  • Normal morning dose of steroid.
  • 100 mg hydrocortisone IV just before anaesthesia. Then:
  • Double oral glucocorticoid dose for 48 hours.

Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case:

  • 50 mg hydrocortisone IM 6 hours until eating and drinking normally.
  • Once well, return to oral dose as above. After 48 hours:
  • If well, return to patient’s normal dose.

Induction of Labour

  • Continue normal dose of steroid until labour diagnosed.

Labour

When labour is diagnosed:

  • 100 mg hydrocortisone IV at onset of labour.

Then:

  • Commence infusion of hydrocortisone at 200mg IV over 24hr

OR

  • 50mg hydrocortisone every 6hrs IM.

Then:

  • Double oral glucocorticoid dose for 48 hours postpartum.
  • Unless the patient is not tolerating oral intake, or is vomiting or unwell, in which case use the IM route as above.

After 48 hours:

  • If well, return to patient’s normal dose.

Special Points

All women at risk of adrenal crisis should consider carrying a Steroid Emergency Card to alert healthcare professionals.

Women who are deficient in glucocorticoids are also at risk of hypoglycaemia. 

  • Check capillary blood glucose and a formal laboratory glucose when first assessed and if the patient develops any symptoms of hypoglycaemia. 

If patient becomes hypotensive, drowsy or peripherally shut down, give 100mg hydrocortisone IM or

IV immediately. (Intravenous doses should be administered over 10 minutes.) 

IM hydrocortisone is preferable to IV since it has a more sustained release. 

Use hydrocortisone sodium phosphate or hydrocortisone sodium succinate, not hydrocortisone acetate. 

If the patient is unwell postpartum (e.g. vomiting or fever), delay return to normal dose beyond the 48 hour period stated above. If the patient is nil by mouth, ensure adequate intravenous fluid replacement (e.g. 0.9% sodium chloride or Hartmann’s solution). 

Monitor electrolytes and BP post-partum: 

  • BP every 4 hours.
  • U&Es daily for 2-3 days.

Appendix 1 Long-term oral glucocorticoids (ie 4 weeks or longer)

Long-term oral glucocorticoids (ie 4 weeks or longer) – Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

MedicineDose (*) 
Beclometasone 625 microgram per day or more 
Betamethasone750 microgram per day or more 
Budesonide1.5mg per day or more (***) 
Deflazacort 6mg per day or more 
Dexamethasone 500 microgram per day or more (**)4
Hydrocortisone 15mg per day or more (**)
Methylprednisolone4mg per day or more 
Prednisone5mg per day or more 
Prednisolone5mg per day or more  

(*) dose equivalent from BNF except (**) where dose reflects that described in the guideline by Simpson et al (2020)4 and (***) based on best estimate

Appendix 2 Inhaled glucocorticoid doses

Inhaled glucocorticoid doses - Taken from Society of Endocrinology, Exogenous steroids treatment in adults2

Medicine

Dose (*)5

Beclometasone          

(as non-proprietary, Clenil, Easihaler, or Soprobec)

More than 1000 microgram per day 

Beclometasone         

(as Qvar, Kelhale or Fostair )       

More than 500 microgram per day

(check if using combination inhaler and MART regimen) 

Budesonide      

More than 1000 microgram per day 

(check if using combination inhaler and MART regimen) 

Ciclesonide                          

More than 480 microgram per day 

Fluticasone propionate  

More than 500 microgram per day 

Fluticasone furoate          

(as Trelegy and Relvar)

More than 200 microgram per day 

Mometasone                     

More than 800 microgram per day 

(*) dose equivalent - NICE Inhaled corticosteroid doses for NICE’s asthma guideline (2018)

Appendix 3 Topical glucocorticoids

Topical glucocorticoids. 2

Topical steroid treatments

Potency of steroid 

Beclometasone dipropionate 0.025%

Potent 

Betamethasone dipropionate 0.05% and higher

Potent 

Betamethasone valerate 0.1% and higher

Potent 

Clobetasol propionate 0.05% and higher

Very potent 

Diflucortolone valerate 0.1%

Potent 

Diflucortolone valerate 0.3%

Very Potent 

Fluocinonide 0.05%

Potent 

Fluocinolone acetonide 0.025%

Potent 

Fluticasone propionate 0.05%

 Potent 

Hydrocortisone butyrate 0.1%

Potent 

Mometasone 0.1%

Potent

Triamcinolone acetonide 0.1%

Potent

All other topical glucocorticoids available in the UK are either mild or moderate potency.

Editorial Information

Last reviewed: 22/04/2022

Next review date: 01/04/2027

Author(s): Andrew Thomson.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 520

References
  1. Wass JAH, Arlt W. How to Avoid precipitating an acute adrenal crisis. BMJ. 2012; 345: e6333
  2. Erskine D, Simpson H. Exogenous Steroids Treatment in Adults. Adrenal Insufficiency and Adrenal Crisis – Who is at risk and how should they be managed safely. Society for Endocrinology and the British Association of Dermatologists.
  3. Woodcock et al. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. Anaesthesia. 2020; 75: 654-663.
  4. Simpson H, Tomlinson J, Wass J, Bean J, Arlt W. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clinical Medicine (London). 2020; 20 (4): 371-378.
  5. Inhaled corticosteroid doses for NICE’s asthma Guideline. July 2018.